pdf, 2881 KB - Centre for Operations Research and Training

Study Team 

Bella Patel Uttekar 

Sandhya Barge 

Yashwant Deshpande 

Vasant Uttekar 

Jashoda Sharma 

Shweta Shahane

PREFACE 

JSY, Janani Suraksha Yojana, is an integral component of the National Rural Health 

Mission, launched in April 2005. JSY aims to reduce maternal and neo-natal mortality by 

promoting institutional deliveries, focusing on women living below the poverty line (BPL). 

Another core strategy of the NRHM is to have a female Accredited Social Health Activist 

(ASHA) for every village with a 1,000 population to act as an interface between the 

community and the public health system. As a volunteer she receives performance-based 

compensation for promoting a variety of primary health care services such as referral and 

escort services for institutional deliveries, universal immunization, DOTS treatment for 

tuberculosis or construction of sanitary toilets. 

In response to a request by the Ministry of Health and Family Welfare (MoHFW) to assess 

JSY in West Bengal, the German Technical Cooperation (GTZ) partnered with the Centre for 

Operations Research and Training (CORT) to conduct the study. The aim was to assess the 

current status of the ASHA intervention and JSY in three districts of Himachal Pradesh, 

Chamba, Shimla and Una. The present report documents the findings of the assessment, 

highlights evidence of success as well as points out areas that need to be addressed in 

order to further improve JSY. This document aims to provide useful information for policy 

makers and programme managers at the national and state levels for further 

strengthening the scheme as well as to develop training and IEC strategies and 

campaigns. It may also be pointed out here that the study was conducted in the initial 

stages of the programme being implemented in the state which has been undergoing 

modifications and the situation remains dynamic. As far as possible we have tried to 

incorporate all the themes, but in case of any lapses we are responsible for the same. 

We are very grateful to Mr. K. D. Maiti, Director, Ministry of Health and Family Welfare for 

his valuable inputs in framing the questionnaire and analyzing data. We would also like to 

acknowledge Dr. Dinesh Baswal, ASHA Training Coordinator at national level and 

Dr. Negi, Officer on Special Duty, Directorate of Health Services, NRHM and Mr. Mauhan 

Chauhan, NRHM Mission Director Himachal Pradesh, CMO of the selected districts for all 

the support extended by them. 

At the outset, we take this opportunity to thank the GTZ Health Sector Support (HSS) for 

having entrusted the work of conducting the assessment to CORT. Our sincere thanks are 

due to Dr. J.P. Steinmann, Principal Advisor Health, Dr. Paula Quigley, Program Advisor, 

Ms. Judith Buesch, Project Manager, and Dr. Urvashi Chandra Technical Specialist, for the 

cooperation extended to us during the various stages of the study. We appreciate their 

inputs in helping us develop the research tools, in administering the study in the field and 

commenting on the draft report. We are especially thankful to Ms. Judith Buesch and 

Dr. Paula Quigley for their meticulous work, quick replies and immense patience. 

We thank our respondents – officers at the state, district and block levels, trainers of 

ASHA, PRI members, members of CBOs, ASHAs, ANMs, community members and of 

course the JSY beneficiaries without whose cooperation it would not have been possible to 

complete the study successfully. 

I wish to put on record my deep appreciation for Dr. Bella Patel Uttekar, the Principal 

Investigator of this project, and all the team members for contributing their might in the 

success of this project and thereby ensuring quality. 

Prof. M. M. Gandotra, Director 

Centre for Operations Research and 

Training (CORT), Vadodara

CONTENT 

Executive summary ..................................................................................................... i-vi 

Chapter 1: Introduction 

Background .................................................................................................................... 1 

Objective of the study.............................................................................................. 2 

Study design............................................................................................................ 3 

Study area ...................................................................................................................... 3 

The sample..................................................................................................................... 3 

Interviews of AWWs .................................................................................................. 4 

Interviews of beneficiaries of JSY.............................................................................. 4 

Other stakeholders................................................................................................... 4 

Community members............................................................................................... 5 

Study tools ..................................................................................................................... 5 

Field operations.............................................................................................................. 5 

Ethical considerations .................................................................................................... 5 

Data management and analysis ..................................................................................... 6 

Presentation of the report .............................................................................................. 6 

Chapter 2: Operationalization of ASHA Intervention and JSY in 

Himachal Pradesh 

State scenario................................................................................................................. 7 

Adaptation and operationalization of ASHA intervention............................................... 8 

Programme management processes .............................................................................. 9 

Selection of ASHAs ......................................................................................................... 9 

Training of ASHAs ........................................................................................................ 10 

Compensation package for ASHAs............................................................................... 11 

Adaptation of JSY guidelines and its operationalization............................................... 12 

Linkages and integration.............................................................................................. 14 

Accreditation of private institutions ............................................................................. 15 

Monitoring and supervision ......................................................................................... 16 

Community’s perception about ASHA and JSY ............................................................. 16

Chapter 3: Involvement of AWW in JSY 

Background characteristics of AWW..............................................................................19 

Awareness and opinion of AWW about ASHA.......................................................... 20 

Training of AWW ...........................................................................................................20 

Quality of Training........................................................................................................ 21 

Knowledge of AWW about ANC and child care services................................................22 

Knowledge of pregnancy and delivery complications and actions to be taken.............22 

Knowledge about newborn care ...................................................................................23 

Knowledge about responsibilities of AWWs ..................................................................23 

Organization of work by AWWs ....................................................................................24 

Availability and utilization of drug kits.........................................................................25 

AWWs role in JSY...........................................................................................................25 

AWWs awareness about cash assistance under JSY ......................................................26 

Promoting JSY ...............................................................................................................26 

Accompanying JSY cases and arranging for institutional delivery ................................27 

Cooperation and cash assistance payment to JSY beneficiaries....................................27 

Handling of delivery at natal place ...............................................................................28 

AWW’s views about preference for home delivery among women................................28 

AWW’s clientele.............................................................................................................29 

Networking of AWW ......................................................................................................30 

The role of other stakeholders .....................................................................................31 

Panchayati Raj Institute...........................................................................................31 

NGOs/CBOs ............................................................................................................32 

Block officials..........................................................................................................32 

Incentives received as AWWs ........................................................................................32 

Supervision and monitoring of AWW ............................................................................33 

Opinion about the JSY component................................................................................33 

Difficulties and challenges faced by AWW ....................................................................34 

Chapter 4: Beneficiaries of JSY in Himachal Pradesh 

Background information of JSY beneficiaries................................................................37 

Awareness about JSY.............................................................................................. 37 

Process of registration under JSY ........................................................................... 38 

Utilization of ANC services by JSY beneficiaries...................................................... 38 

Role of health personnel in helping JSY beneficiaries ...................................................40 

Role of health personnel in micro-birth planning ........................................................40 

Intention versus actual place of delivery.......................................................................41 

Motivation and decision making for institutional delivery............................................41 

Impact of JSY on institutional delivery ..........................................................................42 

Process of arranging transport .....................................................................................42 

Difficulties faced in reaching the place of delivery .......................................................43 

Persons accompanying JSY beneficiaries to the health institution................................44 

Quality of services available at the place of delivery.....................................................44 

Payments incurred for services at the health centre.....................................................44 

Satisfaction with the services at the place of delivery...................................................45

Suggestions for improvement of institutional facilities................................................ 45 

Decision making process of deciding for home delivery.............................................. 45 

Persons who assisted delivery at home and views about TBA...................................... 46 

Dynamics of delivery at home ...................................................................................... 46 

Who prefers delivery at home? ..................................................................................... 47 

Mode of payment and difficulties faced ....................................................................... 47 

Use of cash assistance received for delivery ................................................................ 48 

Appreciation of JSY by the beneficiaries....................................................................... 48 

Complications during delivery...................................................................................... 49 

Child mortality ............................................................................................................. 49 

Chapter 5: Evidences of Success, Challenges and Policy and 

Programme Implications 

Programme management............................................................................................. 51 

ANM’s contribution to JSY...................................................................................... 52 

Cash assistance............................................................................................................ 52 

Increasing institutional delivery ................................................................................... 53 

Community perceptions about ASHA and JSY .............................................................. 53 

Challenges 

Implementation of ASHA .............................................................................................. 54 

Involvement of AWW .............................................................................................. 55 

ANMs participation ................................................................................................ 55 

Accessibility of services ......................................................................................... 55 

Readiness of facilities ............................................................................................ 56 

Ensuring quality of service in the facility................................................................ 56 

Cash assistance under the scheme ........................................................................ 56 

Policy and Programme Implications 

Policy and programme implications ....................................................................... 58 

Policy............................................................................................................................ 58 

Programme management............................................................................................. 58 

Demand generation...................................................................................................... 59 

Appendix 1: ASHAs tables .................................................................................... 61-84 

Appendix 2: JSY tables ......................................................................................... 85-102

LIST OF TABLES 

Table 1.1: Sample covered for qualitative and quantitative components in 

Himachal Pradesh .................................................................................. 4 

Table 2.1: Number of JSY beneficiaries by place of delivery from service statistics 

in Himachal Pradesh up to March 2007................................................. 7 

Table 2.2: Mother’s cash assistance package for JSY beneficiaries in Himachal 

Pradesh .................................................................................................. 13 

Table 4.1: Intention versus actual place of delivery, Himachal Pradesh ................. 41 

Table 4.2: Shift in the place of delivery before and after JSY, Himachal Pradesh.... 42 

Table 5.1: Motivational factors leading to institutional delivery as against 

intension, Himachal Pradesh.................................................................... 53 

Table 5.2: Pregnancy expenditure as against the amount received by JSY 

beneficiaries, Himachal Pradesh ............................................................ 57

LIST OF FIGURES 

Figure 3.1: Knowledge of AWWS – ANC and child care in Himachal Pradesh............. 22 

Figure 3.2: AWW’s awareness about her responsibilities........................................... 23 

Figure 3.3: Network of AWW with stakeholders......................................................... 30 

Figure 4.1: Time when the beneficiary heard about the JSY ...................................... 37 

Figure 4.2: Help provided by health personnel to JSY beneficiaries .......................... 40 

Figure 4.2: Sufficiency of cash incentives received by JSY beneficiary....................... 48

Appendix 1: AWWs Tables 

APPENDIX TABLES 

AWWs interviewed in Himachal Pradesh ................................................ 61 

Table A1: Profile of AWWs in Himachal Pradesh, 2007.......................................... 61 

Table A2: Work history of AWWs in Himachal Pradesh, 2007................................ 62 

Table A3: Number of living children and place of previous delivery for AWWs in 

Himachal Pradesh, 2007........................................................................ 62 

Table A4: Source of information and selection of Anganwadi workers in 


Table A5: Topics covered and arrangements made in the training of AWWs in 


Table A6: AWWs views on logistic arrangements at the place of training, 


Table A7: Views about the training among AWWs in Himachal Pradesh, 2007 .... 65 

Table A8: Payments received during training by AWW in Himachal Pradesh, 

2007 ...................................................................................................... 65 

Table A9: Scoring of knowledge of AWWS in Himachal Pradesh, 2007.................. 65 

Table A10: Knowledge of AWWs about ANC care in Himachal Pradesh, 2007......... 66 

Table A11: Knowledge about complications during pregnancy among AWWs in 


Table A12: Knowledge about common complications during pregnancy / 

delivery that can result into death of a woman, Himachal Pradesh, 

2007 ...................................................................................................... 67 

Table A13: Knowledge about immunization and child care among AWWs in 


Table A14: Responsibilities, recognition and feelings about being an AWW in 


Table A15: Functioning of AWWs in Himachal Pradesh, 2007 ................................. 69 

Table A16: Knowledge about care for pregnant women, Himachal Pradesh, 2007 . 69 

Table A17: Availability and utilization of drug kits by AWWs in Himachal Pradesh, 

2007 ...................................................................................................... 70 

Table A18: Awareness about JSY and its benefits among AWWs in Himachal 

Pradesh, 2007........................................................................................ 71 

Table A19: Cash assistance available under different schemes for AWW and JSY 

beneficiaries in Himachal Pradesh, 2007............................................... 72 

Table A20: AWW’s role in promoting JSY in Himachal Pradesh, 2007 ..................... 72 

Table A21: Role of AWWs in accompanying JSY cases and arranging for 

institutional delivery in Himachal Pradesh 2007.................................... 73 

Table A22: Average time taken to reach the institution by distance of the facility 

from residence of JSY beneficiary , Himachal Pradesh, 2007 ................ 73 

Table A23: Cooperation and cash assistance received at the place of delivery as 

perceived by AWW in Himachal Pradesh 2007....................................... 74

Table A24 Handling of women visiting natal place (other village) for delivery in 

Himachal Pradesh, 2007 ....................................................................... 75 

Table A25: Reasons for preferring home delivery despite cash assistance for 

institutional delivery, Himachal Pradesh, 2007 ..................................... 75 

Table A26: Brief details of AWW’s interaction with her last client in Himachal 

Pradesh, 2007 ....................................................................................... 76 

Table A27: Details of AWWs when last accompanied women for delivery in 


Table A28: Networking of Anganwadi worker with other stakeholders in Himachal 

Pradesh, 2007 ....................................................................................... 77 

Table A29: The roles of other stakeholders in the implementation of AWWs in 


Table A30: Process of receiving cash incentive money as AWW in Himachal 

Pradesh, 2007 ....................................................................................... 79 

Table A31: Average amount received from government (other than training) by 

AWW in the last three months ............................................................... 79 

Table A32: Reported satisfaction with the cash incentive in Himachal Pradesh, 

2007...................................................................................................... 80 

Table A33: Supervision and monitoring of AWW in Himachal Pradesh, 2007 ......... 81 

Table A34: Knowledge and opinion of AWWs about their work with the 

government in Himachal Pradesh, 2007 ............................................... 82 

Table A35: Suggestions of AWW for further strengthening their work in Himachal 

Pradesh, 2007 ....................................................................................... 83 

Table A36: Difficulties and challenges faced by AWW in carrying out activities in 


Appendix 2: JSY Tables 

Coverage of sample in Himachal Pradesh 85 

Table J1: Background information of JSY beneficiary, Himachal Pradesh, 2007 .. 85 

Table J2: Source and type of information heard about JSY in Himachal Pradesh, 

2007...................................................................................................... 86 

Table J3: Process of registration, Himachal Pradesh, 2007.................................. 87 

Table J4: Awareness about index pregnancy, Himachal Pradesh, 2007............... 87 

Table J5: Contacts with health personnel during index pregnancy, Himachal 

Pradesh, 2007 

88 

Table J6: Frequency and place of antenatal check-ups during index pregnancy, 


Table J7: Persons who motivated JSY beneficiaries for antenatal check-ups in 


Table J8: Persons who accompanied the beneficiary and cost incurred for ANC 

visits, Himachal Pradesh, 2007 ............................................................. 89 

Table J9: Reasons for not seeking ANC services, Himachal Pradesh, 2007 ......... 90 

Table J10: Role of AWW to JSY beneficiary during index delivery in Himachal 

Pradesh, 2007 ....................................................................................... 90 

Table J11: Intentional and actual place of delivery among JSY beneficiaries, 


Table J12: Intention versus actual place of delivery, Himachal Pradesh, 2007 ...... 91

Table J13: Rationale for choosing place of delivery, Himachal Pradesh, 2007 ....... 92 

Table J14: Shift in the place of delivery before and after JSY, Himachal Pradesh, 

2007 ...................................................................................................... 92 

Table J15: Process of arranging transport to reach health institution, Himachal 

Pradesh, 2007........................................................................................ 93 

Table J16: Process of arranging money to pay for transport to reach the 

institution, Himachal Pradesh, 2007 

93 

Table J17: Difficulties faced in reaching the place of delivery, Himachal Pradesh, 

2007 ...................................................................................................... 94 

Table J18: Persons accompanying JSY beneficiaries to the health institution, 


Table J19: Quality of services available at the place of delivery, Himachal 

Pradesh, 2007........................................................................................ 95 

Table J20: Payments made for services at the health centre, Himachal Pradesh, 

2007 ...................................................................................................... 95 

Table J21: Satisfaction with the services at the place of delivery, Himachal 

Pradesh, 2007........................................................................................ 96 

Table J22: Improvement necessary at the institution in Himachal Pradesh, 2007.. 96 

Table J23: Rationale for JSY beneficiaries to deliver at home and information they 

had regarding institutional delivery....................................................... 97 

Table J24: Persons who assisted delivery at home, Himachal Pradesh, 2007......... 98 

Table J25: Views about TBA, Himachal Pradesh, 2007 ........................................... 98 

Table J26: Perceived reasons for women to deliver at home despite cash 

assistance paid under JSY for institutional delivery, Himachal 

Pradesh, 2007........................................................................................ 99 

Table J27: Background information of JSY beneficiaries, Himachal Pradesh, 2007 99 

Table J28: Contact with health personnel during index pregnancy by place of 

delivery, Himachal Pradesh, 2007 ......................................................... 99 

Table J29: Utilization of ANC services during index pregnancy by place of 

delivery, Himachal Pradesh, 2007 ......................................................... 100 

Table J30: Payment made to JSY beneficiaries in Himachal Pradesh, 2007 ............ 100 

Table J31: Difficulties faced by JSY beneficiaries in getting cash assistance for 

delivery in Himachal Pradesh, 2007 ...................................................... 101 

Table J32: Opinions on JSY among beneficiaries in Himachal Pradesh, 2007......... 101 

Table J33: Complications during index pregnancy, Himachal Pradesh, 2007 ........ 102 

Table J34: Profile of last and last but one child, Himachal Pradesh, 2007 ............. 102

EXECUTIVE SUMMARY 

Towards achieving the objectives of the National Rural Health Mission (NRHM), Janani 

Suraksha Yojana was launched in April 2005 to promote institutional deliveries 

among the BPL population through provision of referral, transport and escort services. 

JSY integrates cash assistance with delivery and post delivery care for women to have 

healthy outcomes of pregnancy and childbirth. The NRHM aims to have a villagebased 

female Accredited Social Health Activist (ASHA) in 18 high focused states, 

which are low performing with respect to institutional deliveries, to act as the 

interface between the community and the rural public health system and negotiate 

health care for poor women and children. ASHAs would reinforce community action 

for universal immunization, safe delivery, newborn care, prevention of water borne 

and communicable diseases, improved nutrition and promotion of household toilets. 

They would inform, interact, mobilize and facilitate improved access to preventive 

and promotive healthcare, and have drug kits to provide basic curative care. In 

Himachal Pradesh, AWWs are responsible for these tasks until ASHAs are selected, 

trained and in position. 

The Ministry of Health and Family Welfare (MoHFW) decided to undertake an 

assessment of JSY. The Centre for Operations Research and Training, CORT, based at 

Vadodara conducted this assessment of JSY for GTZ and the MoHFW to understand 

the process of implementation of the programme, involvement of AWWs and 

experiences of JSY beneficiaries. This report is based on the qualitative and 

quantitative assessment of JSY in Himachal Pradesh covering three districts of 

Chamba, Shimla and Una. Using semi-structured study tools, 150 AWWs and 237 JSY 

beneficiaries were interviewed through a quantitative survey. In-depth interviews 

were conducted with key persons associated with the implementation of JSY. 

Implementation of ASHA Intervention and JSY 

As per the national guidelines, Himachal Pradesh with 29 percent institutional 

deliveries as per NFHS-2 and 45 percent of institutional deliveries as per NFHS-3 is 

categorized as a high performing state. However, as per NFHS-2, the proportion of 

institutional deliveries among poor women is only 14 percent. As per the service 

statistics, only 16 percent of the deliveries among JSY beneficiaries were institutional 

deliveries. The GOI has approved the ASHA intervention on 15 th November 2006. The 

implementation of the ASHA intervention is taking place in a phased manner, while in 

phase 1, 40 out of 75 blocks would be covered by mid 2007 and the remaining 35 

blocks by 2008. Considering the difficult terrain and sparsely located villages, the 

state has suggested engaging approximately 7,750 ASHAs, one for every 800 

population. Until ASHAs are functional, Anganwadi workers are provided with the 

incentives of Rs 50 per case for the promotion of institutional deliveries and Rs. 25 

for each immunization session that she attends.

Centre for Operations Research and Training, Vadodara 

At the state level, Mission Director, NRHM and an officer on special duty give 

directives to implement the programme. At the district level, Chief Medical Officers 

cum Nodal Officer and Block Medical Officer at the block level would implement the 

trainings and programme activities, as well as monitor the programme. 

At the village level, Gram Sabha, Panchayat, Palikas, PHC/SC staff, sarpanch, ANM, 

AWW and SHGs are to provide ANC and PNC services. Besides, Swasthya Parivaar 

Kalyan Salahkar Samiti would take all the decisions concerning spending of untied 

funds at the sub-centres. The state conducted three-day training of the state trainers 

by NIHFW and six days training of district trainers in Dec 06 – Jan 07. Block trainers 

were to be trained during April-May 2007. 

The state JSY nodal officer administers JSY. CMO and BMO in-charge are responsible 

for JSY intervention at district and block level. The scheme was publicized through 

print and electronic media. Though 77 percent women in rural areas have access to 

TV, the poor women- the JSY target population, and people in the community were 

largely unaware of the programme details. 

As Himachal Pradesh is a high performing state, only BPL pregnant women and SC/ST 

women irrespective of their financial status aged 19 years or more were eligible to 

receive cash assistance up to two live births. The cash assistance includes Rs. 700 for 

women in rural area and Rs. 600 for those belonging to urban areas. Besides, for 

delivery at home only BPL women with same criteria receive Rs. 500. Currently, the 

untied funds are managed at Block and PHC level and process of decentralization of 

administration power was yet to start. 

The process of accreditation of private institutions was to be initiated. Monitoring and 

supervision is taking place at all the levels, with state officials playing a key role. Yet, 

there is a need to develop a simple and sustainable monitoring system. 

Involvement of AWW in JSY 

Most of the AWWs are middle-aged, educated and married staying in the same village 

where they were functioning. Thirty-five percent of the AWWs belonged to SC/ST or 

other backward classes and 65 percent belonged to high caste Hindus. Before JSY, 64 

percent of the AWWs themselves delivered their child at home. 

On average, the respondents worked as AWW for 104.7 months (9 years) and they 

received rupees 1206.5 monthly from working as AWW. 

Forty-one percent of the respondents first came to know about the ASHA from ANM 

and 14 percent from health personnel. Government doctors, TV, radio, hoardings, 

pamphlets, CDPO/ICDS office, and other anganwadi workers also informed them 

about ASHAs. 

A probing to AWWs about their thoughts of having ASHA as a co-worker at the village 

level revealed that 79 percent said ASHAs would be useful to the AWW and only one 

percent did say that ASHAs would not be useful to them. One-fifth of the AWWs did 

ii

Executive Summary 

not specify reasons for believing that ASHAs would be helpful or not, but majority 

(59 percent) said that ASHAs would help AWWs in health related work and 

immunization, and ASHAs can provide information to AWWs about the community and 

people’s health needs. 

In Himachal Pradesh, training of AWWs was done, on average, 8 months ago. Majority 

(71 percent) of the AWWs attended trainings conducted at Anganwadi centre/ 

balbhavan and nursing training center. Logistic arrangements during training 

including sitting arrangements (13 percent), accommodation (22 percent), food 

arrangements (22 percent), and size of the room (24 percent) were rated as average 

by the AWWs. AWWs appreciated the training sessions including trainers and training 

methods feeling they were good and useful. On average they received Rs. 216 as 

training allowance. 

Fifty percent of the AWWs scored Grade A 

or O for answering 8-10 out of 10 

questions correctly, while another 43 

percent scored Grade B. 

Grade B 

Figure 3.1: Knowledge of AWWs - 

ANC & Child Care in Himachal 

Pradesh 

Grade A 

AWWs knew about the complications 

during pregnancy, but only 4–19 percent 

talked about abnormal position of foetus, 

43% 

49% 

weak or no foetal movement, high fever, 

feeling uneasy and body/back pain. In 

such situation, AWWs said that they 

would immediately refer the pregnant 

Grade C 

7% 

Grade O 

1% 

woman to the nearest functional FRU or to a government accredited hospital, while 17 

percent said that they would ask the pregnant woman to consult the ANM the next 

day. 

As per AWWs, their main responsibilities were to help in immunization programme 

(82 percent), create awareness on health (59 percent), and registration of birth and 

death (45 percent), while 39 percent AWW mentioned about mobilizing community to 

utilize health services and create awareness about basic sanitation and hygiene. 

AWWs also promote good health practices, family planning, provide ANC care, preeducation 

for small children, and nutritious food to pregnant women and children. 

Only eight percent of AWWs mentioned about accompanying delivery cases. AWWs 

mentioned about house-to-house (92 percent), talk during VLCC meetings, besides 

attending immunization session (65 percent), organizing health days and attending 

camp (20 percent), and accompanying ANM for conducted their work (17 percent). 

AWWs provided constellation of services and played a potential role in providing 

primary medical care as their last client came seeking services related to get advice 

about immunization (41 percent), registration of pregnancy (31 percent), for getting 

BPL card (21 percent), medicine for fever/vomiting/back pain (16 percent), nutrition 

(13 percent) and place of delivery (12 percent), sterilization (11 percent), ANC care 

(7 percent), and for receiving IFA tablets (6 percent). 

iii


Forty-three percent of the AWWs had accompanied an average of 2.8 JSY cases for 

institutional delivery, mainly to government hospitals, PHCs and CHCs. Anganwadi 

workers accompanied the last case around 109 days ago while only six percent of 

them stayed with JSY beneficiaries at the place of delivery. 

AWWs network with the various stakeholders in the village to implement JSY. All the 

AWWs met ANMs, followed by PRI (87 percent), SHG (82 percent), PHC staff (71 

percent) and village mandals (50 percent). They also met block facilitators, Health and 

Sanitation Committee and NGO staff. 

Only 18 percent of the AWWs received some cash incentive money, mainly for 

immunization of children and attending JSY beneficiaries. Thirty-three percent AWWs 

were satisfied or somewhat satisfied with the cash incentives mainly because they were 

able to serve people and received payment. Sixty-three AWWs were unsatisfied with 

the cash assistance as it was ‘too much of work and too little money’ (53 percent), or 

did not get JSY money from ANM (21 percent) and because of delay in payment (13 

percent). 

AWWs spent on average 5.5 hours every week in preparing various registers while 

AWW’s work was mostly monitored by anganwadi supervisors, ANMs and MO PHC. 

Beneficiaries of JSY in Himachal Pradesh 

The JSY beneficiaries were young (23.6 years) and mostly those who had schooling up 

to primary, middle or secondary level. Sixty percent of the JSY beneficiaries belonged 

to SC/SC and five percent to the other backward classes. 

The beneficiaries learnt about JSY during various stages of pregnancy, however, 27 

percent learnt about the scheme only after their delivery from ANM (48 percent), 

Anganwadi centre (36 percent) and doctor (23 percent). Only one-fifth of the JSY 

beneficiaries got registered in the first trimester, and on average, women had 3.7 

antenatal check-ups during their index (JSY) pregnancy. Husbands (72 percent), 

mother-in-law (36 percent) and sister-in-law (17 percent) accompanied the 

beneficiary for ANC visit(s). Thirty-four percent of the women received antenatal care 

at district/sub-district hospital, 32 percent at sub-centre and 16 percent each at PHC 

and home. 

Majority (55–68 percent) 

of the JSY beneficiary 

received advice about 

diet, delivery care and 

newborn care, 

breastfeeding, while 

advice regarding danger 

Intended place for last delivery 

Institutional 

At home 

Intention versus actual place of delivery 

Place where last delivery of JSY 

beneficiary took place 

Institutional At home Total 

32.5 (77) 

15.2 (36) 

7.6 (18) 

44.7 (106) 

40.1 (95) 

59.9 (142) 

Total 47.7 (113) 52.3 (124) 100.0 (237) 

signs and family planning was mentioned by 44 percent each. Fifty-eight percent of 

the beneficiaries were told about four or more aspects (out of 5) of micro-birth 

planning. The cross-tab of intention vs. actual place of delivery shows interesting 

results. Of the total JSY beneficiaries interviewed, eight percent (n=18) women 

iv

Executive Summary 

delivered at home though they intended to deliver at a hospital because of lack of 

time to reach the hospital, due to extreme poverty and opposition from family 

members. 

Only 15 percent (n=36) of those beneficiaries that intended to deliver at home finally 

opted institutional delivery due to complications (58 percent), safety of mother and 

child (14 percent), as per motivation provided by relatives to go for institutional 

delivery (11 percent) and non availability of TBA in the village (6 percent). Majority (34 

percent) of the institutional deliveries took place in district/sub-district hospitals. 

Among all beneficiaries who opted for institutional deliveries safety of both mother 

and child (77 percent), better access to institutional delivery services (30 percent) and 

cash assistance (26 percent) were mentioned as motivating factors while only 12 

percent named support provided by AWWs. 

Out of the 100 JSY beneficiaries who had two or more children, 57 percent of the 

previous deliveries were reported delivery at home. Twenty-four percent of the 

women with two or more children continued with institutional delivery and 46 percent 

with delivery at home. However, between two deliveries, 11 percent (n=11) of the 

beneficiaries shifted from home to institution due to complications and safety of the 

child. 

In Himachal Pradesh, JSY beneficiaries had to travel, on average, 22.4 kms to reach 

the ultimate place of delivery. Women spent approximately 1 hour and 8 minutes to 

arrange transport and reach the ultimate place of delivery and another 1 hour and 2 

minutes after reaching the institution on registration and administrative process and 

as waiting time until someone attend them. 

Twenty-four percent of the JSY beneficiaries did not receive their cash assistance, 

while 90 percent of those who received cash got payment in one go (much before the 

delivery (26 percent) or much later after the delivery (28 percent)) from the ANM or 

CHC/PHC MO. The JSY beneficiaries spent an average of Rs. 1231.1 during ANC 

period, Rs. 528.6 for transportation to the place of delivery and Rs. 3732.9 for 

delivery, against which they received an average of Rs. 587.8 from the government as 

cash assistance. 

The study evidently reveals that the cash assistance is not enough to cover all 

expenses for institutional deliveries with women spending a substantial amount out 

of their own pockets. For those, who delivered at home, 17 percent had negative 

balance and others gained Rs. 175 on average. While in the case of institutional 

deliveries, 75 percent spent more than what they received, on average an additional 

Rs. 2830.7. Forty-one percent of the JSY beneficiaries felt that the cash assistance 

received was not sufficient. 

It is encouraging that husbands (86 percent) and mother-in-laws (59 percent) as well 

as other family members (43 percent) accompanied women for delivery. Mothers, 

neighbours, AWW, ANM, dai and government doctor also accompanied the women. 

On average, after normal delivery (n=89) and assisted delivery (n=3) women were 

discharged after 24 hours and for caesarean (n=21) after 5 days. 

v


Most of the women were satisfied with JSY and would recommend relatives or friends/ 

neighbours to be a beneficiary under JSY, mainly due to cash assistance, safety of 

mothers, good services at hospital and because poor families receive help. 

JSY beneficiaries perceived that despite cash assistance paid under JSY, women still 

prefer to deliver at home because of extreme poverty, shyness, hospital expenses, 

fear of doctors, and clinics located far away. 

The process of programme implementation such as selection and training of ASHAs 

was yet to be initiated. In the absence of ASHA anganwadi centers are bridging the 

gap though the role of anganwadi workers in JSY is minimal. Seven percent of the 

interviewed beneficiaries said that AWWs actually decided for institutional delivery on 

behalf of the JSY beneficiary; five percent arranged transport and two percent AWWs 

accompanied women to the health institution. Besides, the quality of care and 

infrastructure at the facilities particularly PHCs and sub-centre needs to be improved 

to provide services for normal deliveries. 

vi

Chapter 1 

Introduction 

Background 

The Government of India launched the National Rural Health Mission (NRHM), in 2005. 

The aim was to provide accessible, accountable, affordable, effective and reliable 

primary health care, especially to the poor and vulnerable sections of the population. 

The Mission envisages equitable, and quality health care services to rural women and 

children in the country with greater emphasis on 18 highly focused states. It adopts a 

synergistic approach by encompassing non-health determinants that have a bearing 

on health such as nutrition, sanitation, and safe drinking water. The mission also 

aims to achieve greater convergence amongst related social development sectors. 

To accomplish the goals, one of the core strategies proposed was to have a female 

Accredited Social Health Activist (ASHA) for every village covering a 1,000 population. 

ASHA would be chosen by and would be accountable to the panchayat to act as an 

interface between the community and the public health system. As an honorary 

volunteer ASHA would receive performance-based compensation for promoting 

variety of primary health care services in general and reproductive and child health 

services in particular such as universal immunization, referral and escort services for 

institutional deliveries, construction of household toilets, and other healthcare 

interventions. 

In order to enable the states for proper implementation, detailed ASHA guidelines 

have been prepared by the Ministry of Health and Family Welfare (MOHFW), 

Government of India (GoI) wherein institutional arrangements, roles and 

responsibilities, integration with ANM and Anganwadi workers, working 

arrangements, training, compensation, fund-flow etc have been discussed. Further, 

training modules and facilitators guide have been prepared and shared with the states 

for training programmes. The guidelines have accorded flexibility to the states in 

designing the operationalization of the intervention. Many states depending on the 

local context have modified the guidelines to suit their requirements. 

As part of NRHM, the Honorable Prime Minister of the country launched safe 

motherhood intervention in the form of Janani Suraksha Yojana (JSY) for reducing 

maternal and neo-natal mortality on April 12, 2005. The scheme aims to promote 

institutional deliveries among pregnant women below poverty line in all the states and 

Union Territories (UTs) of the country with special focus on low performing states 

(LPS). It is a 100 percent centrally sponsored scheme and links cash assistance with 

delivery and post-delivery care. In availing institutional delivery services, the client 

needs to be escorted, need transport to reach the institution. In case of 

complications, referral services are required. The scheme has considered all these


elements and has made provision for transport including referral and escort (by 

ASHAs) and at the same time invested in improving public health institutions and 

services through the Reproductive and Child Health (RCH) Programme interventions. 

Moreover, the states have flexibility to evolve public-private partnership (PPP) 

mechanism and accredit private health institutions for providing institutional delivery 

services. 

As stated earlier, for LPS, in both rural and urban areas, special dispensation is 

available and linked to the ASHA intervention. The LPS are states that have 

institutional delivery rates below 25 percent and include Uttar Pradesh, Uttaranchal, 

Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa, and 

Jammu and Kashmir. In the remaining states and UT’s categorized as High Performing 

States (HPS) similar provisions have been made wherein anganwadi worker, traditional 

birth attendant, ASHAs or ASHA like activists could be engaged and be associated 

with JSY. To facilitate the states in implementing JSY, a set of guidelines articulating 

the criteria of eligibility of beneficiaries and provisions were worked out in detail. The 

guidelines since inception of the scheme have undergone four revisions and certain 

clauses were modified for both LPS and HPS states. 

Both ASHA intervention and JSY are in operation for over a year and the LPS are in 

different stages of implementation. To understand the status of implementation and 

the processes adopted for operationalization in the states of Assam, Himachal 

Pradesh and West Bengal, MOHFW sought the assistance of GTZ. GTZ commissioned 

it through a professional research agency Centre for Operations Research and 

Training (CORT) based in Vadodara, Gujarat. 

Objectives of the Study 

The common objectives for ASHA and JSY were as under: 

1. Review adaptation of the national guidelines by states and its 

operationalization 

2. Study programme management processes (planning, MIS and supervisions, 

etc.) and institutional arrangements established for implementation of the 

schemes. 

3. Analyze funds flow mechanisms from state to district and to lower levels of 

service delivery system and reimbursement. 

4. Ascertain the level of understanding about these two schemes amongst the 

programme managers, service providers and other stakeholders 

5. Map community perceptions about the two schemes 

For ASHA intervention study attempted to: 

1. Assess adherence with guidelines for community involvement / NGOs / CBOs 

in the selection of ASHA 

2. Review the training strategy including design, plans, material developed, 

training of trainers, quality of training and post-training follow-ups 

3. Analyze support of health system to AWW who were promoting JSY till 

ASHAs are in place 

2

Introduction 

4. Study engagement of PRI, NGO, SHGs and other CBOs engagement in 

extending support to ASHA 

For JSY, specific objectives were as under: 

1. Assess adequacy and simplicity of the processes set out by the state for 

claiming benefits under JSY 

2. Examine the utilization of the scheme and analyze factors influencing 

impeding utilization 

3. Understand the factors responsible for home delivery over institutional 

delivery among JSY beneficiaries 

4. Review engagement of private sector including accreditation and 

compensation 

5. Analyze nature and scope of IEC interventions for raising awareness of JSY. 

Study Design 

The assessment of ASHA and JSY was based on a blended methodology and included 

application of quantitative and qualitative techniques. The study covered three 

districts of Himachal Pradesh, one good, average and poor performing district, 

selected on the basis of performance in the context of number of JSY beneficiaries 

and percentage of institutional deliveries among those JSY beneficiaries. The NRHM 

Mission Director, Department of Health and Family Welfare, Himachal Pradesh 

provided data regarding the number of JSY beneficiaries in each district as well as 

information regarding the distribution of cash assistance to those beneficiaries. Based 

on this information the place of delivery (home or institutional) could be determined. 

Subsequently, districts were grouped as good, average and poor performing districts. 

The selection process was discussed with the State officials prior to finalization of 

study districts by GTZ. Likewise, a procedure of district-level consultation and 

secondary data review was undertaken in each of the districts to select two blocks by 

CORT. Thus, in all six blocks from three districts were covered in Himachal Pradesh. 

Study Area 

This report is based on the 

assessment study conducted 

in Himachal Pradesh covering 

Chamba, Shimla, and Una 

districts. 

The Sample 

The sample covered in the 

state included Anganwadi 

workers and beneficiaries of 

JSY. In the state of Himachal 

Pradesh, ASHAs are yet to be 

recruited and trained. Until 

then, Anganwadi workers 

have been engaged to 

3


promote JSY. Several other people associated with the scheme such as state and 

district programme managers, block-level providers, Auxiliary Nurse Midwife (ANMs), 

members of Panchayati Raj Institutions (PRIs), Community Based Organizations 

(CBOs), and community members were interviewed and included in the study. 

Interviews of AWWs: In all, 150 AWWs interviewed from the state and included in the 

study. From each of the six study blocks, 30 AWWs were to be interviewed. However, 

several posts of AWW were vacant and we could identify only 20–26 AWWs per block, 

except for Gagret Block in Una district. Therefore, in Una block 35 AWWs were 

interviewed. To cover 30 AWWs, nearly 30 villages/hills were visited in each of the 

study block, which included one CHC village, 2 PHC villages; 9 sub-centre villages (3 

SCs within each selected PHC/CHC), and 18 remote villages (2 remote villages from 

each of the selected sub-centre). 

Interviews of beneficiaries of JSY: Altogether, 237 JSY beneficiaries who availed 

services under the scheme were interviewed. As per the proposal it was envisaged 

that the beneficiaries would be selected among those who had availed services in the 

six months prior to the survey, but to achieve the desired sample this could not be 

adhered to. It was further plan to include 40 percent (96 cases) institutional deliveries 

and 60 percent (144 cases) home deliveries from the study districts. From each of the 

study block, 40 JSY beneficiaries were planned to be interviewed. However, in 

Himachal Pradesh due to non-availability of JSY beneficiaries in the four blocks of 

Mashobara, Sunni, Amb, and Tissa fewer than 40 cases could be interviewed. To 

compensate for this, in Gagret and Pukhari block 46 and 51 JSY beneficiaries were 

interviewed respectively. List of JSY beneficiaries was availed from PHC and SC to 

select the name of the beneficiary. Given the number of JSY beneficiaries in each of 

the list, almost all were approached if available for the interview. ANMs and 

Anganwadi workers at times helped in locating the respondent. Given the nature of 

settlement pattern and geographical terrain of the area this was essential. 

Other stakeholders: In addition to 

quantitative survey of JSY beneficiaries, 

other people including state and 

district programme managers, blocklevel 

providers, nodal officers, Chief 

Medical Officers, State and District 

Accounts Manager, ANMs, PRIs, CBOs, 

and community members were also 

interviewed. 

In Himachal Pradesh, Mission Director, 

NRHM, an Officer on special duty, 

Table 1.1: Sample covered for qualitative component 

in Himachal Pradesh 

Type of stakeholders Number of stakeholders 

interviewed 

Qualitative study 

State officials 1 

District level officers 7 

Block level provider 10 

PRI/NGO/SHGs 17 

ANMs 58 

Community members 15 

Quantitative survey 

JSY Beneficiaries 237 

Anganwadi workers 150 

Directorate of Health Services and State nodal officer were interviewed by the GTZ 

representative. Specific questions related to the implementation of the scheme, 

processes involved and challenges faced were addressed to them. The state Nodal 

Officer was also approached and discussions were held on adaptation of national 

guidelines, selection and training of ASHA, suggestions and challenges faced. Three 

block development officers were interviewed about the utilization of the scheme, and 

4

Introduction 

steps required for future improvement of the scheme. Again, at block level, Block 

Medical Officer of Health, members of Panchayati Raj Institutions, NGOs, self-help 

groups, CBOs, and ANMs were interviewed to assess the networking of ASHA its 

benefits and challenges. 

Community members: Awareness and understanding of the scheme at the community 

level is important to enhance utilization of the scheme. Informants both male and 

female, in each district were asked about their awareness of the programmes, 

attitude, and utilization. In each of the study block, four key informants, two males 

and two females, were interviewed in-depth regarding various aspects of the scheme. 

Study Tool 

The study tools were developed by CORT in collaboration with the professionals from 

UNFPA, Ministry of Health and Family Welfare, and GTZ. Several questions were openended. 

After the fieldwork in the first state of Rajasthan (done in collaboration with 

the UNFPA), based on the responses from Rajasthan, several open-ended questions 

were modified to close ended questions. Probing questions related to home deliveries 

were added for the states of Himachal Pradesh and West Bengal after the fieldwork in 

Assam was completed. For qualitative in-depth interviews, guidelines were used for 

collecting the requisite information from the stakeholders. The guidelines facilitated 

in the comparison and analysis of data across respondents within the state. The type 

of queries addressed differed depending on the type of stakeholder, including 

adaptation of the national guidelines, programme management processes, funds flow 

mechanisms, and community perceptions about JSY. 

Field Operations 

Experienced Field Manager and Field Coordinators from social sciences coordinated 

the entire fieldwork. Fourteen field investigators, males and females were trained at 

Shimla for six days to conduct the fieldwork. 

At the grassroots level, female field investigators interviewed JSY beneficiaries. 

Supervisors checked the selection of the eligible sample and ensured that the 

questionnaires were filled accurately and completely. GTZ professionals actively 

participated during the fieldwork, facilitated the fieldwork and helped in ensuring the 

quality of data. Back-checks conducted at site ensured consistency in the data 

thereby ensuring quality, validity and reliability. Fieldwork in Himachal Pradesh was 

carried out during March 10 th 2007 to April 15 th 2007. 

Ethical Considerations 

MOHFW and GTZ had informed the authorities of the selected states, districts and 

blocks about the study and the need to share the information about ASHAs and JSY 

beneficiaries with the research team of CORT. The field coordinators ascertained that 

informed consent procedures were pursued and that privacy and confidentiality was 

ensured during interviews to minimize the potential for distress, if any. The research 

staff did not share individual information obtained during the study with staff of any 

other organization. 

5


Data Management and Analysis 

CORT’s in house specialist, who has been involved in the complete analysis of largescale 

surveys like NFHS and RCH, handled the data management and analysis. The 

CORT programmer prepared data entry screens for the study using CS Pro. A data 

entry package was developed by CORT for the study, which checked range and 

consistency. This was used to enter data collected from the field. Double data entry 

was done to ensure the quality of data entry and eliminate mistakes, if any. 

The analysis of data was done using SPSS package. The data was tabulated and 

analysed as per the analysis plan developed by CORT, GTZ and UNFPA. Preliminary 

results were shared with the GTZ and their suggestions and feedback were 

incorporated in the final report. 

Presentation of the Report 

The report has five main chapters, apart from Preface and Executive Summary. The 

present one gives a brief introduction of ASHA component and JSY and the study 

design for assessment. Chapter 2 elucidates programme inputs and processes 

adopted in implementation of the scheme in the state of Himachal Pradesh. AWW’s 

profile, selection, training, knowledge about different aspects of reproductive and 

child health and other related issues are discussed in Chapter 3 while utilization of 

JSY by the beneficiaries, their views about the scheme and suggestions, are discussed 

in Chapter 4. Chapter 5 provides an overview of evidence of success, challenges and 

policy and programme implications for enhancing ASHA intervention and JSY. 

6

Chapter 2 

Operationalization of ASHA Intervention and JSY 

in Himachal Pradesh 

The features and implementation of ASHA intervention and Janani Suraksha Yojana 

(JSY) are discussed in this chapter. It includes an understanding of JSY amongst 

stakeholders, the process of decentralization, and funds flow mechanisms. State and 

district officials were interviewed to get their perceptions regarding the linkages and 

integration amongst ANM, Anganwadi workers and other stakeholders. Their support, 

monitoring and supervision are also highlighted in the chapter. The findings are 

based on in-depth interviews conducted with the Mission Director NRHM and an 

Officer on Special Duty, Directorate of Health Services, NRHM at the state level. 

Besides, at the district level, Chief Medical Officers cum Nodal Officer and Chief 

Medical Officers, Finance Officers (FOs), Block Medical Officer (BMO), Block Mo 

Finance of the three districts were interviewed to understand the implementation of 

JSY. 

State Scenario 

According to the National Family Health Survey (NFHS) 3, in 2006, in Himachal 

Pradesh 45 percent of births took place in health facilities as opposed to 29 percent 

during 1998-99, while 61 

percent of deliveries took 

place in the women’s own 

and 10 percent in their 

parents’ homes. In rural 

areas, only 25 percent of the 

total deliveries took place in 

health institution. Though 

Himachal Pradesh is 

categorizing as a high 

performing state, the 

proportion of institutional 

Table 2.1: Number of JSY beneficiaries by place of delivery from 

service statistics in Himachal Pradesh up to March, 2007 

Number of deliveries 

(April 06 – Feb 07) 

Home Institutional 

deliveries delivery 

Total 

beneficiaries 

Percentage 

institution 

delivery 

Total number of 

JSY beneficiaries in 

Himachal Pradesh 

4185 

Chamba NA NA 596 NA 

Shimla 537 203 740 27.4 

Una 

NA : Not available 

273 32 305 10.6 

deliveries among women from households with a low standard of living is only 14 

percent. (Standard of living was measured through possession of durable goods in 

the household. In a range of 0 to 67 as the maximum score, those scoring 14 or 

below have been considered as low standard of living index.) NFHS-2 also reveals that 

amongst other backward class, only 20 percent of the deliveries took place in health 

facilities. As per the service statistics, during April 06 to February 07, only 16 percent 

of the deliveries among JSY beneficiaries were institutional deliveries. 

The Government of India has recently sanctioned the ASHA intervention for the state 

of Himachal Pradesh. Thereby, the Project Implementation Plan was prepared 

including the ASHA intervention and was approved by the GOI on 15 th November


2006. The following sections give details about the implementation of JSY in the state 

of Himachal Pradesh. 

Adaptation and Operationalization of ASHA Intervention 

The Government of India has issued detailed guidelines for implementing ASHA, 

covering various aspects including roles and responsibilities of ASHA, institutional 

arrangements, selection and training of ASHAs, working arrangements, and linkages 

with Anganwadi Workers and ANMs, compensation to ASHAs, fund-flow mechanism 

and evaluation. The States have been given some flexibility to modify the guidelines, 

if felt necessary. The state has decided to implement the scheme in a phased manner. 

In the first phase, 40 out of 75 blocks would be covered by mid 2007 and the 

remaining 35 blocks would be covered by 2007-08. Considering the difficult terrain 

and villages that are sparsely located, the state has suggested reducing the 

population to be covered by an ASHA from 1,000 to 800. Moreover, in far off remote 

areas a state official suggested to further relax the norms. The official further added 

that ASHAs working with smaller population would not be able to earn enough money 

in terms of their services. Therefore, top-level officials in the state of Himachal 

Pradesh were yet to decide on the selection process of ASHA, their area coverage, and 

cash incentives. In an interview prior to the actual data collection in December 2006, 

a senior state official stated: 

“We have received the ASHA guidelines from the GOI that talks about a 

facilitator at Block level who would go to the villages and hold focus group 

discussions to identify potential candidates as ASHAs . We are yet to takea decision on the selection process part of the ASHA. We have to see to what 

extent we can implement the guidelines issued by the GOI or what 

modifications are required”. 

The communication from the national to the state level and state to the district level 

has been quick. All the concerned officials at the state and district levels are informed 

about JSY. Since initially ASHAs were not intended to be appointed AWWs were 

entrusted with the responsibility of managing JSY. 

In December 2006, a senior state official said, 

“We are yet to work out the exact numbers of ASHAs requir ed. We have to 

see the topography of the area … the population i s quite spread out. Often 

there are only one or two or up to five households in a village situated on a 

hill top.” 

The number of ASHAs required to cover the entire state of Himachal Pradesh has been 

worked out considering the topography of the area, and the sparse distribution of the 

population. The health department decided to engage approximately 7750 ASHAs, 

one for every 800 population. 

8

Operationalization of ASHA Intervention and JSY in Himachal Pradesh 

Until ASHAs are functional, Anganwadi workers are provided with the incentive of 

Rs. 50 per case for the promotion of institutional deliveries including motivating and 

accompanying women to the nearest institution for delivery. The state has 8,000 

Anganwadi centres and another 14,000 are sanctioned. According to the state 

officials, the AWWs are active in the state and have been performing well. They are 

engaged in organizing several health activities such as immunization, antenatal check 

ups, and health days at the Anganwadi centres. Moreover, health functionaries like 

ANM, Medical Officer, and Lady Health Supervisors support AWW in organizing village 

health day at the Anganwadi centres. Together they motivate the pregnant women for 

antenatal check up and children for immunization. 

Programme Management Processes 

At the State level, NRHM Mission Director, and an officer on special duty provides 

overall guidance and directives to the implementing agencies in the district. At the 

district level, the Nodal officer and Programme Manager provides technical help to the 

Chief Medical Officer, Deputy CMOH to implement and monitor the scheme and 

facilitates the implementation of the training in the district. They also sensitize the 

Panchayat and other stakeholders about the selection process and role of ASHAs. 

At the block level, the Block Medical Officer and health supervisors manage the 

programme, network with stakeholders, and implement IEC programmes. 

At the village level, Gram Sabha, Panchayat, Palikas, PHC/SC staff, ANM, SHG 

members and AWWs are the key implementers of the programme. At the community 

level, there are Palikas who are Swasthya Parivaar Kalyan Salahkar Samiti, which is 

working at Panchayat level. It was constituted at the sub-centre level to begin with. 

Palikas are constituted at the level of Gram Panchayat constituting of members from 

the community; a local health worker, ANM, ASHA as well as the AWW. They would 

take all the decisions concerning spending of untied funds at the sub-centre. 

Selection of ASHAs 

As per the selection criteria in the national guidelines, ASHAs should be a resident of 

the village, who is at least eighth grade pass between 25 and 45 years of age. In 

Himachal Pradesh, according to the state officials, the state would be adhering to the 

GOI guidelines. Himachal Pradesh has a literacy rate above the national average and 

hence getting the required number of 7750 literate ASHAs should not be a problem. 

There are many educated women available in the villages. A nodal officer explained 

the process of selection and said that, 

“We went to the villages and conducted out reach camps in each village to 

identify three candidates for ASHA. Out of these three the gram-sabha 

approved one name. The gram-sabha then gave the name to the PHC/CHC 

Medical Officer or the Block Medical Officer.” 

9


However, qualitative interviews showed that since selection of ASHAs has not taken 

momentum yet, PRI members were not yet involved in the selection process. The PRIs 

were not aware about the eligibility criteria, the expected role of ASHAs and her 

linkages with the ANM. A PRI member in Chamba said, 

“I am not aware about ASHA. I think the scheme has not started in Himachal 

Pradesh. There is no selection of ASHA in our village”. 

Another member of a gram-sabha said, 

“Around 10 days back , ANM told me something about ASHA. According to 

that a woman from the village would be selected, who is at least 10th pass to 

work as ASHA”. 

For ASHA selection, the ASHA guidelines envisaged the role of a committee 

comprising of gram-sabha, block medical officer, a health supervisor, and ANM. 

Training of ASHAs 

A team from the National Institute of Health and Family Welfare organized a threeday 

training of the state trainers (TOT) at Shimla. Team of district trainers is trained 

for six districts, and in the remaining districts, training of district trainers was ongoing 

at the time of fieldwork for this study. District trainers team consist of Dy. 

CMO, Programme Officer, and 3–4 nurses. Block trainers such as Block Medical 

Officers, a Panchayat member, health activist, had been identified and their training 

would be taken up within a fortnight (that is by April 2007) in several districts. The 

State Official said that, 

“Training of block level trainers would take some time of course, but in the 

meantime we will initiate the process o f selection of ASHAs”. 

The Government of India has 

designed several training 

modules for the ASHA. The state 

government is printing these 

training modules, so training 

would be initiated as soon as 

ASHAs are selected. However, as 

the proposal on the methodology 

of selection of the ASHA is still 

pending with the higher officials 

the process of recruitment has 

not been initiated. 

It is planned to give the induction 

training to ASHAs in a phased 

manner. In the first phase, out of 

the total 75 blocks in the state, 

Roles and Responsibilities of ASHAs 

Create awareness and provide information to the 

community on determinants of health 

Counsel women on importance of safe delivery 

Mobilise the community and facilitate them in 

accessing health services such as antenatal checkup, 

institutional delivery, post natal check-up 

Work with the Village Health and Sanitation 

Committee of the Gram Panchayat 

Escort / accompany pregnant women to the nearest 

pre-identified health facility 

Provide primary medical care for minor ailments 

Act as depot holders of basic medicines, essential 

provisions like oral rehydration therapy, Iron and 

Folic Acid Tablets, and contraceptives 

Inform about the births and deaths in her village 

Promote construction of household toilets 

10


40 blocks covering all the districts would be selected. It was envisaged that by March 

2007, in some of the blocks ASHAs should be in place. The rest of the blocks would 

be covered during 2007 – 08. 

The training programme of ASHA is of 23 days - 7 days of 1 st training and four 

trainings of four days each. First round of training of 7 days would be implemented 

by March 2007 to June 2007. Seven days residential training of ASHAs would be 

organized mainly at the district level. Discussing about the roles and responsibilities 

of ASHAs, a state officer said, 

“ASHAs are basically going to be one among and of the community. 

Essentially she would be working very closely with the community. She would 

look into the everyday health needs of the community and of course she 

would liaison with the AWW centre and the ANM. We are also going to 

provide ASHAs with a small medicine kit for day-to-day ailments such as 

fever or cough. There are other departments, for example. ICDS or Total 

Sanitation campaign with whom she would be working as a motivator for the 

community. She would also work as a facilitato r”. 

Compensation Package for ASHAs 

As per the national guidelines, ASHA receives payment on performance-based which 

is paid by ANM of the concerned sub-centre. Payment to ASHA is being done at the 

ANM level. ANMs monitor the 

activities of ASHA and number of 

pregnant women motivated by ASHAs 

to deliver institutionally, number of 

children immunized by ASHAs. The 

fund for the same is placed at the 

block Medical Officer. Through BMO, 

money would be given to the ANMs. 

The compensation package of ASHA is as follows: 

Full immunization – Rs. 25 

Registration of all pregnant women, three 

ANC and two PNC-Rs 50 

Escorting pregnant women to institutions for 

delivery – Rs. 50 

At present ANMs do not have any money on hand. As a nodal officer added, 

“The scheme ensures that the money must be available with the health 

workers (ANM) working in the community which would enable them to help a 

woman when in need.” 

Currently AWWs are paid Rs. 50 per institutional delivery and Rs. 25 for each 

immunization session that she attends. The state officials raised concerns regarding 

low payment of ASHAs for encouraging institutional deliveries as per compare to 

other state. Since other state in similar situations (HPS) such as West Bengal are 

allowed to pay ASHAs. The state officer said, 

“When we were looking at the incentives under different programmes we saw 

that Himachal has presently been denied the incentive to ASHA under JSY 

because we are a high performing state. I’ve spoken to the GOI and they said 

that the basic aim of the scheme is to promote institutional delivery in states 

where it is below 25 percent. However, at the same time, GOI has allowed 

11


incentive to ASHA under JSY in the North-eastern states where institutional deliverie s are much higher than 25 percent and they are similarly situated as 

our state. We are going to take up ou r case with GOI that they should allow 

incentive under JSY to ASHA in Himachal also. But it’s quite a big amount of 

money, 600 Rupees per ASHA for each case she accompanies”. 

In similar line, a nodal officer opined, 

“ I think that if the cash assistance is fixed, it is much better to keep the 

interest of the 

workers and to motivate them to continue”. 

Adaptation of JSY Guidelines and its Operationalization 

JSY is operational in all the districts of Himachal Pradesh. As mentioned earlier, 

currently JSY is promoted by AWWs. Besides, some selected NGOs, CBOs, and SHGs, 

which are strong in Himachal Pradesh are involved. The state JSY nodal officer 

administers the JSY implementation in the state as per the GOI guidelines. At the 

district level, the Chief Medical Officers are responsible for JSY intervention. 

Programme Manager is responsible for the performance and financial monitoring. At 

the block level, block Medical Officer is the key person implementing the JSY. At the 

community level, ANMs, and Anganwadi workers are responsible and they are 

accountable to PRI members for promoting the scheme. 

To promote JSY, the state has started specific programmes and IEC activities. The 

scheme has been publicized through posters, pamphlets, and wall paintings on the 

walls of PHC and Sub-centres stating the benefits of the JSY scheme. Besides, JSY was 

advertised in the local dailies to inform the masses about the scheme. Radio 

programmes and Radio talks by Mission Director, Programme Officer, and Secretary 

Health are also broadcasted to inform masses about the details of the scheme. A 

nodal officer explained, 

“We got some wall-painting done in Anganwadi centres, and each PHC and 

sub-centre displaying messages about JSY. Besides, our health workers and 

other stakeholders talk about JSY in different level meetings, trainings. The 

message has been circulated to the grass-roots level”. 

A nodal officer suggested that CBOs should come forward and motivate women to 

avail the benefits of JSY. He narrated, 

“IEC materials should be distributed through the Panchayat members. Mahila 

Swasthya Sangh, Mahila Mandals should come forward and motivate women 

to avail the scheme”. 

12


Cash Assistance: According to the National guidelines, in High Performing States, all 

BPL women aged 19 years or more would be eligible to receive cash assistance up to 

two live births (Table 2.2). For home deliveries, again only for BPL pregnant women in 

both rural and urban areas, cash 

assistance of Rs. 500 has been 

sanctioned. Since December 

2006, it was communicated to 

the state and district officials 

including CMO that in addition 

to the BPL women, the benefit of 

the scheme be extended to all 

SC and ST pregnant women, 

irrespective of their financial 

status. 

Table 2.2: Mother’s Cash Assistance Package for JSY 

Beneficiaries in Himachal Pradesh 

Particulars Rural areas Urban areas 

Institutional delivery 

(only for BPL women and all SC/ST 

women 

children) 

aged 19+ up to two 

Home delivery 

(only for BPL women and all SC/ST 

women 

children) 

aged 19+ up to two 

700 600 

500 500 

As per the State Official, women are paid in two instalments – once during their 

antenatal period and secondly on delivering in an institution. He said, 

“As per GOI guideline s, 

the money has to be given one week before delivery 

or one week after the delivery, the package of Rs. 500 plus Rs. 200. But in 

Himachal Pradesh, the Government has taken a decision that Rs 500, which 

comes as a nutrtona i i l support to the women , shoud l be pad i in her third 

trimester and 200 when she delivers in the institution.” 

Talking about the recent change with respect to the eligibility of SC/ST, a 

nodal officer said, 

“Recently all the beneficiaries who are SC/ST have been accepted in the High 

Performing State and they have to be included under the JSY irr espective of 

their financial status.” 

The national JSY guideline envisages that the process of cash assistance payment has 

to be simple. A Chief Medical Officer said, 

“The process of payment i s quite simple. The y (women) need to produce the 

certificate (BPL), actually they are to produce the discharge letter then the 

payment is done immediately at the place of delivery. This is a big 

achievement, I would say”. 

The PRI members heard of the JSY from ANM, male health workers, and during village 

health camps from the government doctor. PRI members also mentioned about health 

department and that they came to know at the sub-centre. In their words, 

“Formal dissemination i s only in health camps or we come to know about the 

scheme if we visit the sub-centre”. 

13


The PRI members were aware of the process of giving cash assistance and the 

package. A PRI member commented, 

“A pregnant woman gets Rs 500 for diet and another Rs. 200 for institutional 

delivery. The process is simple and she gets money for transport also. 

Besides, for delivery with operation (caesarean), she gets Rs. 1500. This is 

what I have heard. The scheme i s good and people should avail benefits of 

it”. 

The process of decentralization of administration power is yet to start, as per the 

national guidelines. District, block and village level stakeholders are yet to be 

involved in implementing JSY. Currently, the untied funds are kept at Block and PHC 

level from where the incentive is given to the AWW. The Block Medical Officers have 

placed some money with the ANM/female health workers who pay cash assistance to 

the pregnant women. The ANMs pay from the money they already have and recoup 

from the Block Medical Officer. When ASHAs are in place, ANM would be getting more 

funds so there may not be any scarcity of funds. Palikas, the village level Swasthya 

Parivaar Kalyan Salahkar Samiti, have been involved in implementing the scheme and 

monitoring the untied funds. Gram-sabha is yet to be enrolled in the funds flow 

mechanism. 

To ensure that the beneficiary is a BPL, PHCs are required to keep the list of BPL 

families with them at the sub-centre level. When a woman visits PHC/sub-centre the 

PHC staff knows that the woman is from a BPL family. In case she does not have a BPL 

certificate, or is a migrant labourer, Pradhan could certify that the woman is actually 

very poor, based on that certification that incentive money can be given to the 

migrant labourer also. Discussing about the payment to the migrants a state officer 

emphasized, 

“Migrant labourers, after all wha t is their economic status? They are very 

poor. They earn thei r bread and butter out of their sweat”. 

Another state official said, 

“Now many industries and hydroelectric projects are coming to the state of 

Himachal Pradesh and with them a lot of migrant workers. These people are 

deprived of benefits pr esently. They need some kind of assistance and are 

now considered in the scheme.” 

Linkages and Integration 

When ASHAs are trained and involved in the programme activities, they need to coordinate 

and work with AWW, ANM and other stakeholders. The AWW and the ANM 

would be the mentors for the ASHA and they would give advice and input to ASHA 

while working at the community. There were a few concerns raised by the state 

officials related to the shifting of responsibilities of promoting institutional delivery 

from AWW to ASHAs. A senior state officer said, 

14


“The cash incentive that we wer e giving to AWWs as mobilization money for 

immunization and to promote institutional delivery will be given to the 

ASHAs subsequently when they start functioning. Naturally there will be 

some repercussion about that but gradually they will understand because 

ASHA has to earn her own bread and butter out of the services she renders 

to the community”. 

A Chief Medical Officer also raised similar concerns saying, 

“When ASHAs start promoting institutional deliverie s, 

the incentive money 

being paid to AWW would be given to ASHAs. Definitely AWWs would not like 

this. It would take time for them to understand and work in a coherent 

manner.” 

At the state and district level, the concerned officers had complete awareness about 

the objectives of JSY, their role and ASHA’s role in the implementation of JSY. The 

other stakeholders at block, district and village level were also aware about JSY, which 

was evident when investigating the involvement of stakeholders in implementing JSY. 

However, some of the Panchayat members interviewed had not heard about JSY. 

Talking further in detail about the scheme, the PRI member said, 

“I heard about the scheme from the male health worker, but I do not know 

any further details about it.” 

Accreditation of Private Institutions 

A private institution with 24x7 days services of gynaecologist, an anaesthetist, and a 

surgeon who could perform caesarean section, has easy access to blood transfusion 

facility, proper OT and labour room with power back up can be considered for 

Accreditation as per the guidelines. In Himachal Pradesh, the process of accreditation 

of private institution is yet to be initiated. The presence of private sector at subdistrict 

and block level is almost non-existent. According to the state officials, 

“Every village is not linked with functional health facility. Most of the villages, 

2 to three villages, have one functional health facility, eithe r from allopathy 

or from ayurveda. Only in Sirmaur and Hamirpur, we have accredited some of 

the nursing homes”. 

“I would like to inform you that, in Himachal Pradesh, 80 percent of the 

service s are provided by the government. We have a very weak private 

infrastructure. We have very limited nursing homes”. 

“Whatever is available, is in the urban areas. But we require service s in the 

interior areas”. 

15


Monitoring and Supervision 

In Himachal Pradesh, Senior state officials monitor and supervise the whole 

implementation of JSY. There are regular meetings of the Chief Medical Officer and 

Block Medical Officers organized by the state to review the process of implementation 

and progress. At the district level, CMOs organize monthly meetings with the block 

officers, health supervisors and other people. The block Medical Officer organizes 

meeting at his level attended by the Medical Officers and health supervisors. PHC MO 

in-charge and Panchayat monitor the programme at the grassroots level. The 

Panchayat members are involved in monitoring both performance and cash flow. 

Explaining the mechanism in details, a state official said, 

“We have developed a mechanism in ou r state that on 18th 

of every month 

sub-centre workers go to the PHC. The PHC medical officer does the review. 

From 20 

s s v 

t r 

c 

th to 25th of every month, the review of the medical officers of the 

PHCs i with the block medical officer . On 26th of e ery month CMO calls 

the block medical officers to the district and does the review. And then CMOs 

are called to the state every alternate month when the Secretary of Health 

reviews the progress by video conference, which we had on day before 

yes erday and one more is scheduled fo tomorrow where CMOs and 

Programme Officers of the concerned district give the feedback to the 

Secretary of Health, Mission Director, and Director of Health Servi es by 

video conference. This way we are monitoring”. 

A health supervisor said. 

“We are not able to supervise properly. So many programmes are there and 

like this (JSY) are linked with money. We have to record properly, check 

properl y. 

We need one more person who could check the accounts.” 

Community’s Perceptions about ASHA and JSY 

In all, 15 community members – both male and female, were interviewed in-depth to 

understand their awareness of the programme, attitude, and utilization. None of the 

community members had heard about ASHA. They said, 

“I have not heard anything about the word ASHA”. 

“We have no idea about ASHA”. 

While regarding JSY the community members said, 

“We know something about the scheme. I have heard about i t from the ANM”. 

“Yes, Anganwadi worke r told me when I met her at the Anganwadi centre. But 

I do not remember the details”. 

“We have not seen any propaganda of the scheme”. 

16


Talking about the details, women in the community said, 

“Only BPL families would get Rs. 500 during pregnancy for food. Thos e who 

go for hospital delivery would get Rs. 200 at the hospital itself. If she has 3 

children o r more, she will not get this benefit. Government also gives Rs. 200 

for transportation”. 

“Hardly 10 percent people in the community would be aware of JSY”. 

A man in the community said, 

“People know less about the scheme”. 

The community members suggested that people in the community should be made 

aware of the scheme to increase the number of beneficiaries. In Una, a young female 

said, 

“As people are less aware about the scheme, they have not availed it s 

benefits. All should be told about the details of the scheme”. 

Community members were asked about the reasons why women prefer home 

delivery. Almost all the informants talked about expenses at the hospital, easy and 

timely availability of the dai, unavailability of doctor at the hospital, lack of transport 

facilities, lack of awareness about JSY scheme, traditional beliefs and fear of hospital 

delivery were the other reasons voiced for women preferring home deliveries. 

The assessment thus shows that the Himachal Pradesh has adopted the national 

guidelines for ASHA and JSY with some suggested modification. The State Health and 

Family Welfare Department is implementing and monitoring JSY. In Himachal Pradesh, 

while the JSY scheme has taken off, the scheme is in its infancy for ASHA involvement. 

PRI members are to be roped in fully and the scheme has to be propagated to 

increase its utilization. Further, the transition of JSY beneficiary responsibility from 

AWW to ASHA will have to be strategically addressed. 

17

Chapter 3 


As mentioned earlier, in Himachal Pradesh, ASHA are yet to be trained and involved in 

organizing demand-side initiatives for effectively promoting JSY and timely utilisation 

of various health related interventions within the programme. Until then, it is planned 

that AWW would act as an interface between vulnerable communities, especially 

women and children, and health care providers to promote their health. 

AWWs have been trained under ICDS for reproductive health to facilitate 

implementation of the Village Health Plan along with ANM, functionaries of other 

Departments, and Self Help Group (SHG) members under the leadership of the Village 

Health Committee of the Panchayat. This chapter describes the socio-demographic 

profile of AWWs, their motivation to be AWW, training, and knowledge retention 

regarding antenatal and childcare. The Chapter also discusses their roles and 

responsibilities, and services provided to pregnant women by them under the JSY. 

Details about AWW’s last clientele (to understand the nature and range of 

interactions), networking with key stakeholders, cash assistance received by AWW, 

their supervision and monitoring, challenges faced and their suggestions for 

improving the scheme are presented in the chapter. 

Background Characteristics of AWW 

In all, 150 AWWs were interviewed from the three districts of Himachal Pradesh. AWWs 

interviewed were middle aged with the average age of 36. Sixty-one percent of the 

AWWs were aged between 30–34 years, while 24 percent were 40 years or more. On 

average, AWWs have had 10 years of schooling. Majority (81 percent) of the AWWs 

studied up to secondary or higher secondary level and (7 percent) were 

undergraduate and above (Table A1). 

Most of the AWWs interviewed were married, 9 percent were unmarried, while 7 

percent were divorced, separated or widowed. All the AWWs were Hindu. Thirty 

percent of the AWWs belonged to scheduled caste/scheduled tribe and 5 percent 

belonged to backward classes. Majority (65 percent) belonged to high caste Hindus. 

It is encouraging to note that 77 percent of the AWWs stayed in the same village 

where they worked AWW and another 21 percent from a village close by. Analysis of 

the data in the study shows that majority (60 percent) of AWWs had 10 and more 

years work experience, while 23 percent were working since 5–9 years and earned, on 

average, Rs. 1200 rupees monthly (Table A2).


Regarding the number of living children of AWWs, the study showed that only sixteen 

percent AWWs had not experienced any childbirth, while, on average, the other AWWs 

had 2.3 living children (Table A3). Majority of the AWWs had 2–3 living children, and 8 

percent had four or more living children. 

All the AWWs who had children were asked about the place where their last child was 

delivered to understand their own practice and behavioural aspects regarding place of 

delivery. The study revealed that 64 percent of the AWWs had delivered their last child 

at home, followed by 33 percent at the government institution, which was in line with 

the trends observed in the community in Himachal Pradesh and reflected community 

behaviour. This ensured that that the selection of AWWs represented the community 

and was done adequately as per the national guidelines. 

Awareness and Opinion of AWW about ASHA 

AWWs were asked about their first source of information about ASHAs, and their 

perceptions about usefulness of the ASHA intervention. 29 percent of the AWWs had 

heard about the ASHA intervention. Of those, 41 percent of the AWWs first came to 

know about the ASHA from ANM and another 13 percent from health personnel. 

Government doctors were first source for 11 percent, while radio, TV, hoardings kept 

at sub-centres, PHC or CHC and CDPO/ICDS office were first source of information for 

7 percent each of the AWWs, while five percent or less of them mentioned about other 

Anganwadi worker working in the area. 

In the earlier chapters concerns of the state officials regarding linkages between AWW 

and ASHAs were raised. A probing to AWWs about their thoughts of having ASHA as a 

co-worker at the village level revealed that 79 percent said ASHAs would be useful to 

the AWW, while one-fifth of them said that they cannot comment about this at the 

moment. One percent of the AWWs did say that ASHAs would not be useful to them. 

One-fifth of the AWWs did not specify reasons for believing that ASHAs would be 

helpful or not, but majority (59 percent) said that ASHAs would help AWWs in health 

related work and immunization, and ASHAs can provide information to AWWs about 

the community and people’s health needs. Some (5 percent) said that it is good for 

people as they can benefit and get cash assistance. Only one or two AWWs envisaged 

that ASHAs would create awareness among women, give information about hospital, 

solve problems of pregnant women, and if ASHA and AWW work with cooperation they 

can yield better results. One AWW said that she works independently and hence does 

not foresee any benefit (Table A4). 

Training of AWW 

Anganwadi workers undergo various types of training under ICDS programme. The 

study shows that 71 percent of the AWWs had attended some training in the last oneyear. 

According to the AWWs, the topics covered during the AWW training programme 

included infant and childcare (immunization) (44 percent), nutrition (34 percent), 

HIV/AIDS (25 percent), and women and health including FP, ANC, breast-feeding (24 

percent). Nineteen percent were given training about the functioning of Anganwadi 

centres, while 14 percent each mentioned adolescent and pre school education and 

20


one-tenth about National Rural Health Mission. Eight percent or less talked about 

sanitation, organizing a group meeting, supply of safe drinking water, reproductive 

and sexual health problems, curative care, and management of diarrhoea and 

pneumonia (Table A5). 

The training of AWWs was done, on average, 8 months ago (July – August 2006) and 

the duration of the training was 5.1 days ranging between one and fifteen days. The 

training was mostly held at AWW centre, balbhavan and nursing training centre. In few 

cases training was held at PHC, CHC, Panchayat, or school. 

Regarding additional arrangement 30 percent of the AWW responded. The common 

suggestions for additional requirements were related to proper beds/bed sheets (38 

percent), latrine/ bathroom facilities (31 percent), and proper water facilities (22 

percent). Every sixth AWW more space required in the training room, electricity and 

fan during training, and the need for having TV, whereas 12 percent mentioned about 

proper food arrangement (Table A5). On further requesting the AWWs to give their 

views by grading the logistic arrangements at the place of training, majority of the 

AWWs appreciated the arrangement for sitting (82 percent), size of the room (72 

percent), accommodation (70 percent) and food facilities (73 percent) as good. Few 

(3–7 percent) AWWs complication about poor accommodation and food arrangements 

(Table A6). 

Quality of Training 

To assess the quality of training, training pedagogy, AWWs were asked to comment 

upon the trainers and the process of training. Majority of the AWWs found the trainers 

to be either very good (45 percent) or good (54 percent). Besides, AWWs found 

training to be participatory and said that the trainers encouraged them to ask 

questions (78 percent) and answered their questions properly (25 percent) (Table A7). 

Majority (83 percent) of the AWWs said that the trainers used charts/models to 

explain the topics. The training aids used included posters (80 percent), lectures, 

book (47 percent) and flip charts (45 percent). One-sixth or less mentioned about 

TV/ video, pamphlets, role plays, folksongs and models to explain the topics 

(Table A8). Thirty-two percent of the AWWs found the training materials to be very 

good and 67 percent found training as good and useful (94 percent) or somewhat 

useful (7 percent). 

Thus, the study reveals that the logistic arrangements at the place of training were 

not proper in relation to the accommodation and food, but AWWs appreciated the 

training including trainers and training methods as good and useful. The topics 

covered during training were mentioned by only one-third of the AWWs, except infant 

and child care (44 percent). Topics such as disposal of waste water, safe drinking 

water, organizing a group meeting and reproductive and sexual health problems or 

management of diarrhoea and pneumonia were mentioned by less than 10 percent of 

the AWWs. These topics need to be readdressed in subsequent training for AWW. 

21


Knowledge of AWW about ANC and Child Care Services 

To assess the knowledge of AWWs, they were asked about various aspects of 

antenatal care taught to them during the training. In the survey, 10 questions related 

to ANC care and newborn care were asked to AWWs and each question answered 

correctly was given one mark. Later, the scores achieved by a particular AWW were 

added up to get total score to understand whether the AWWs were having knowledge 

required for ANC care. 

The total score of all questions was 

categorized as Grade O – (outstanding) 

for 10 out of 10 points, Grade A for 

those who score 8-9, Grade B for those 

who score 6-7, andd Grade C for those 

who score 5 or less. Only one percent 

(n=2) scored O and could answer all the 

ten questions correctly (Table A9). Fortynine 

percent of the AWWs scored Grade 

A, and another 43 percent of them 

scored Grade B. Ten AWWs (7 percent) 

could answer only 5 or less questions 

(Figure 3.1). 

Grade B 

43% 

Figure 3.1: Knowledge of AWWs - 

ANC & Child Care in Himachal 

Grade C 

7% 

Pradesh 

Grade O 

1% 

Grade A 

Further analysis of the specific aspects shows that AWWs had good knowledge about 

antenatal and newborn care (Table A9). For instance, majority (82–100 percent) of the 

AWWs knew about the various aspects of safe motherhood and child care including 

breast feeding and management of diarrhoea, number of TT injections to be taken, 

minimum birth weight of baby, and number of antenatal checkups required during 

pregnancy. Seventy-two percent of the AWWs knew that a minimum of 100 IFA tablets 

are to be consumed during pregnancy and 57 percent knew about all the five cleans 

that need to be maintained during delivery. 

Knowledge of Pregnancy and Delivery Complications and Actions to be 

Taken 

AWWs need to know about the complications women may experience during 

pregnancy for early identification and timely referral. Regarding complications during 

pregnancy AWWs mentioned swelling of hands and feet (67 percent), vomiting (59 

percent) and paleness (46 percent). Thirty-four percent of the AWWs mentioned 

excessive bleeding, while 25 percent mentioned abdomen or body pain, and feeling 

uneasy (19 percent). Fifteen percent of the AWWs mentioned about high fever and 

weak or no movement of foetus (10 percent). Less than 7 percent mentioned visual 

disturbance, abnormal position of foetus, convulsion, or weight loss. The knowledge 

of AWWs regarding complications during pregnancy and delivery was low and may be 

taken up in subsequent rounds of training (Table A10). 

If AWWs recognize any signs of complications among women during pregnancy or 

delivery, 54 percent said that they would immediately refer the pregnant woman to 

the nearest functional FRU including upgraded CHC, subdivision or district hospital. It 

22 

49%


is to be noted that 33 percent of the AWWs said that they would refer pregnant 

woman to a government accredited hospital, while 18 percent of the AWWs ideally 

mentioned that they would take the women with complication to the nearest 

functional FRU, or refer to a private accredited hospital. One-sixth of the AWWs said 

that they would ask the women to consult the ANM the next day (depending on the 

nature of complication). This would further delay the process and timely referral. Only 

one AWW said that she would provide money for transportation to the women. 

AWWs further said that common complications during pregnancy or delivery that 

could result in maternal death could be weakness of the mother (74 percent), 

excessive bleeding (59 percent), blood pressure problem (43 percent), and 16-17 

percent mentioned about abnormal position of the foetus or abdominal pain. Other 

reasons for death could be death of foetus in mother’s womb, and fever. A few (less 

than 3 percent) mentioned about headache, convulsions, or tetanus (Table A11). 

Knowledge about Newborn Care 

Most (95–99 percent) of the AWWs knew about BCG, DPT and measles vaccines by 

names that are to be given to children as part of the Universal Immunization 

Programme. Majority (79 percent) of the AWWs knew about the booster dose and 42 

percent knew about OPV vaccines, while only 31 percent of the AWWs knew tetanus 

toxoid by name. Most of the AWWs said that newborns are most likely to die soon 

after birth (35 percent), within a week of birth (25 percent), or within a month of birth 

(17 percent). The study reveals that 16 percent of the AWWs did not know the period 

when newborns are most likely to die (Table A12). 

Knowledge about 

responsibilities of 

AWWs 

According to the 

AWWs, their main 

responsibilities are to 

help in immunization 

programme (82 

percent), create 

awareness about health 

(59 percent), ensure 

registration of birth 

and death (45 percent) 

and mobilize 

community to utilize 

health services (39 

percent). A third of the 

AWW mentioned about 

creating awareness 

about basic sanitation 

and hygiene, followed 

by village health 

Figure 3.2: AWWs' awareness about her responsibilities 

Help in immunization program 

Create awareness on health 

Registration of birth and death 

Motivating and mobilizing community 

Create awareness on basic sanitation & hygiene 

Village health planning 

Provide basic curative care 

Promote good health practices 

Pre education for small children 

Motivate pregnant women for nutrition 

Accompanying delivery cases 

Work with ANM/dai 

Make timely referrals 

23 

Family planning 

Provide ANC care 

Counseling 

Other 

7 

6 

8 

8 

9 

15 

12 

17 

15 

19 

25 

23 

31 

39 

45 

59 

82 

0 20 40 60 80 100


planning (25 percent), providing basic curative care, promoting good health and 

family planning practices as their responsibilities. Only 15 percent or less said that 

their responsibilities are to provide antenatal care, pre school education, provide 

nutrition to children and 8 percent AWWs each mentioned accompanying delivery 

cases, counselling, working with ANM, and make timely referrals. Adolescent 

education was also mentioned as one of the responsibilities of the AWWs (Table A14). 

To increase the utilization of the services of AWWs, it is important that the community 

recognize AWWs and know their role in the village. In 57 percent of the cases, AWWs 

felt that people in the village recognize them because of their work in the community 

and in the role of Anganwadi (42 percent). Another 30 percent AWWs each said that 

they themselves informed the villagers, or the villagers knew her as a well-wisher or a 

good worker, while 16 percent said that they attend meetings at the health centre so 

people could recognize them as AWWs. People also knew that AWW can get them 

money and the gram sabha or Sarpanch introduced 7 percent AWWs to the villager 

who also know them as working with ANM. 

Most (99 percent) of the respondents were happy an AWW, as they got the 

opportunity to serve the community (17 percent); they learn new things, which they 

pass on to the community (7 percent) and got to know more about health. A few 

AWWs commented that it would be better if they received more money. 

AWWs felt happy because poor people get benefits such as JSY through them (61 

percent), they have increased knowledge and understanding (30 percent) and they 

created awareness among ignorant and poor people in the community. Besides, she 

personally came to know about ANC (22 percent), and get respect and support from 

the villagers (21 percent). AWWs said that they were happy being AWW as people in 

the village recognize her and as they got to know people and doctors in the village. 

Monetary gain, working with children, and reducing misconceptions were other 

reasons for liking the job of AWWs. 

All the AWWs were asked how the community felt about them, most (97 percent) of 

the AWWs thought that the community appreciate their work, but only 9 percent said 

that women consulted them for health problems. 

Organization of Work by AWWs 

All the AWWs were asked about the process of carrying out their work. Most (92 

percent) of the AWWs said that they visited house, and 65 percent said that they 

attended immunization session, and 20 percent AWWs organized health day at 

Anganwadi centre. Another 17 percent of the AWWs said that they accompanying 

ANMs, and only 6 percent accompanying women for delivery (Table 15). 

All the AWWs were asked about the advice and services given to a woman during 

antenatal and postnatal period. Most (95 percent) of the AWWs said that they advised 

pregnant woman regarding diet, and 77 and 66 percent mentioned about 

immunization and ANC care (to have three check-ups and take IFA tables and TT 

injections) respectively. Fifty-one percent of the AWWs mentioned giving advice 

24


related to institutional delivery, 25 percent about delivery care and 22 percent about 

breast-feeding. Only some AWWs talked about maintaining personal hygiene, danger 

signs, newborn care, family planning or about breast care. 

As for the services to pregnant woman, 93 percent of the AWWs mentioned that they 

gave nutritious food, 64 percent ensured that woman took IFA tablets, 51 percent 

advised for antenatal check-up, and one-fifth each accompanied pregnant woman for 

TT and for ANC check-up. Only few (2 percent) AWWs talked about attending 

outreach day or identifying risk factors in antenatal mothers (Table 16). 

Majority (62–77 percent) of the AWWs said that during post partum period, they 

advised woman regarding breast-feeding, nutrition, immunization, and newborn care. 

Follow-up regime was explained by 27 percent of the AWWs. Only few AWWs 

mentioned childhood morbidity management, hygiene, or family planning. AWWs 

were asked to suggest actions to further enhance services in the community. Only few 

AWWs could suggest and mainly they suggested for increasing awareness among 

people about JSY, upgrading facilities, promote family planning, and increase pay of 

AWW. They also suggested that there is a need for lady doctor to enhance services 

besides increasing awareness about health in the community. 

Availability and Utilization of Drug Kits 

AWWs are given drug kits to provide basic medicines to the people, when required. 

The study reveals that almost all the AWWs had a drug kit. 19 percent AWWs received 

drug kit some days after training, while 35 percent AWWs received drug kit much later 

after their training. The drugs and materials mainly supplied in the drug kit to AWWs 

are paracetamol, IFA, ORS packets, tincher, ear/eye drops, paediatric drugs, cough 

syrup and Dicyclomine Hydrochloride tablet. AWWs who had reportedly received the 

drug kit mentioned bandage, cotton, thread, needle, blade, scissor and soap. It is to 

be noted that AWWs mentioning availability of Mala D, condom or Mamta kit was only 

4, 3 and less than one percent respectively . 

Most of the AWWs who received the drug kit had used the medicines available in the 

kit about 73 days ago, on average. The last time when AWWs used the drug kit, they 

dispensed paracetamol tablets (90 percent), and 20 percent each IFA and ORS packet. 

Less than 10 percent mentioned about tincher, eye drop, Dicyclomine Hydrochloride 

tablets, paediatric drugs, cough syrup, Chloroquine Phosphate tablets. However, only 

one AWW mentioned about giving condom or delivery kit. The medicines are mostly 

replenished at CDPO/ICDS office or other Anganwadi worker. Some AWWs got 

supplies from ANM or PHC/CHC (Table 17). 

AWW’s Role in JSY 

In Himachal Pradesh, majority (84 percent) of the AWWs had heard about JSY. The first 

source of information is mainly ANM (61 percent) or other PHC staff (21 percent), 

while 15 percent said that they first heard about JSY during training or from AWW (10 

percent). ICDS/CDPO office (8 percent), male health worker/supervisor, village 

panchayat leader, women in the community and TV/newspaper/radio were the first 

source of information about JSY for only few. 

25


When AWWs were asked about JSY, 68 and 64 percent respectively mentioned it as a 

scheme for poor family for getting cash assistance and for promotion of institutional 

delivery. Forty-eight percent of the AWWs said that the scheme was for intake of 

nutritious food and 41 percent mentioned about benefit of mothers. Twenty-six and 

19 percent mentioned immunizing children and registration of birth and death 

respectively, while only 7-8 percent mentioned that JSY was to promote family 

planning. Some of the AWWs understood JSY as scheme for population stabilization 

and for rich and better off families. 

Nearly 98 percent of the AWWs said that women from BPL families could be the 

beneficiaries, while only 13 percent AWWs knew about the recent changes including 

women from SC/ST who could be the beneficiary. Some AWWs mentioned that all 

pregnant women or those with less than two children, and members of IRDP 

(Integrated Rural Development Programme) could be eligible for JSY. Few of the AWWs 

mentioned women above 19 years of age as possible beneficiaries (Table 18). 

To identify possible beneficiaries, most (79 percent) of the AWWs pay home visits, 

and 36 percent said that if a woman felt uneasy or was vomiting, they took her to the 

hospital. IRDP registers and Panchayat records of BPL families were also mentioned by 

AWWs as means to identify possible beneficiaries. Four percent of the AWWs said that 

ANM informed them about the pregnant women. 

AWW’s Awareness about Cash Assistance under JSY 

Each of the AWWs interviewed was asked about the cash assistance available to AWW 

and JSY beneficiaries. Chapter 1 gave details of the payment package as propagated 

by the state. Majority (58 percent) of the AWWs said that they do not get anything 

from various schemes, while only (18 percent) of the AWWs mentioned about the cash 

incentive available to them for accompanying women for delivery, attending delivery 

cases (6 percent). Two percent or less mentioned about getting money for 

transportation for escorting women for delivery or immunization. 

As regarding cash assistance to the JSY beneficiaries, 67 percent of the AWWs 

mentioned that they get money for home delivery and 50 percent mentioned about 

cash assistance for institutional delivery. Twelve percent mentioned getting 

nutritional supplements from Anganwadi centre, while 6 percent or less mentioned 

that beneficiaries get free transport to hospital, free medicines, treatment, delivery, 

immunization besides, protection of mother and child health, and quality services. 

One AWW mentioned Rs 400 for sterilization. 

Promoting JSY 

As expected, most (94 percent) of the AWWs said that they played a role in promoting 

JSY. To promote JSY, they talked to women (86 percent), conduct door-to-door visit 

(56 percent), and publicise JSY during immunization and health days, camp days and 

talk in VLCC. Besides the women, 2 percent of the AWW talk to males and 27 percent 

talk to other family members in the household. All the AWWs considered the work 

under JSY as very important (45 percent) or important (53 percent) as compared to 

other tasks that they had to fulfil as AWW. 

26


All the AWWs were invited to express views about and suggest ways for further 

promotion of JSY. Many of the AWWs suggested door-to-door visits (71 percent), 

advertisement (58 percent), giving more financial benefits to AWW (39 percent), and 

organizing village level meetings (39 percent). Nearly one-tenth of the AWWs thought 

that JSY could be promoted through satisfied beneficiaries (Table A20). 

Accompanying JSY Cases and Arranging for Institutional Delivery 

All the AWWs were asked details about accompanying JYS cases, and arrangements 

made thereof. The study shows that 43 percent of the AWWs had accompanied JSY 

cases for institutional delivery. On average, AWWs had escorted 2.8 cases for 

institutional delivery ranging between one to 8 cases per AWW. A majority of 57 

percent had not accompanied any woman for institutional delivery, while one-tenth 

had accompanied only one woman, so far, for institutional delivery. Nineteen percent 

had accompanied three or more women for institutional delivery. Majority (69 

percent) of the AWWs take women to government hospital or PHC (22 percent) and 

eleven percent to CHC. According to the state officials private network is not that 

developed in the state and was mentioned by less than two percent of the AWWs. 

AWW suggested private vehicles or client’s own vehicle (79 percent) to transfer a case 

from village to health facility and 7 percent depended on public transportation 

(Table A21). 

AWWs were asked how they usually arranged for transport. Sixty seven percent of the 

AWWs said that they called transporters over phone, while 24 percent of them would 

call from the village, if transport facility is available. Ten percent of the AWWs said 

that families themselves arrange the transport, and another nine percent would tell 

the transporters and/or give money to the transporter in advance. Only two percent 

each would use private shuttle vehicle, or keep contact with transporters. 

Regarding the availability of transport, 84 percent of the AWWs said that transport 

facility was always available. It is crucial to note that 16 percent of the AWW said that 

transport was not always available. The average time taken to arrange for the 

transport was to be 34 minutes with maximum time taken up to three hours to 

arrange for the transport. Further, the average distance to the referral facility was 12 

kms ranging between no distance and 60 kms. The study also reveals that it took 

43.3 minutes, on average, and maximum of 6 hours to reach the institution. 

Depending on the distance to the facility from residence of JSY beneficiary, the time 

varied from an average of 12 minutes to 85 minutes (Table A21). One to 4 percent of 

the AWWs did not know the details about transportation or distance and time taken to 

reach the ultimate place of delivery. 

Cooperation and Cash Assistance Payment to JSY beneficiaries 

All the AWWs interviewed were asked about the cooperation at the institution and the 

process of paying cash assistance to JSY beneficiaries. Majority (85 percent) of the 

AWWs said that the cooperation received at the institution was very good or good. 

However, 11 percent said that the cooperation was neither good nor bad or that there 

was bad or no cooperation at the institution (Table A23). 

27


All the AWWs were asked details about the process of disbursing cash assistance to 

the beneficiaries at the place of delivery. Sixty-three percent of the AWWs were aware 

and mentioned that the beneficiary women were given cash assistance. Majority (36 

percent) reported Rs 1200 and 38 percent mentioned Rs 500 (that was given till 

November 2006) as the amount received by beneficiaries for institutional deliveries. 

Some 13 percent AWWs mentioned Rs 700 – 1000, while another one percent 

mentioned Rs. 1600 as cash assistance for delivery. 

According to the AWWs, ANM/male health worker (57 percent), accountant, clerk, or 

babu (21 percent), doctor at the institute (17 percent), and the MO CHC/PHC made 

the payments to the beneficiaries. 

Thirty three percent AWWs said that the payment of cash assistance to the beneficiary 

was given immediately after delivery and another 22 percent mentioned that cash 

assistance was given within a week after the delivery. Moreover, thirty seven percent 

said that cash was given before delivery or at the time of registration, whereas the 

remaining eight percent did not know about the timing of giving cash assistance. 

In most (71 percent) cases, the payment was done in one go at the PHC (35 percent), 

or at the place of delivery (27 percent). Twelve percent of the AWWs each said that 

payment was done at the CHC and within the village or at home. 

Thirteen percent of the AWWs mentioned that there were delays in beneficiary 

receiving the money mainly because of lack of budget at the centre (75 percent), 

doctor’s signature (25 percent), or long queues to collect money. Senior officials at 

the state level said that cash flow has never been a problem. However, AWWs stated 

that a substantial proportion of the beneficiaries did not receive cash assistance in 

one go because of lack of budget at the centre. 

Handling of Delivery at Natal Place 

Each AWW was asked about how they handle cases where a woman goes to her natal 

place for delivery in another village. In such situation, majority (40 percent) of the 

AWWs said that they ask her to take proper care and go for institution delivery and 39 

percent would asked women to get benefit at her natal place. Twelve percent AWWs 

would make sure that the woman gets the benefit, and eleven percent said that 

women would receive the money at the place of delivery, hence there is no problem. 

Less than seven percent AWWs talked about giving JSY card and referral slip from the 

village, take care of immunization of the child, accompany women to the place of 

delivery (even at the natal place) or ask women to call her at the time of delivery. 

According to two percent of the AWWs, they would try to convince women to deliver 

in the same village, or that AWW at woman’s natal place would take care. Twenty four 

percent of the AWWs had no such case until now (Table A24). 

AWW’s views about Preference for Home Delivery among Women 

Despite cash assistance paid under JSY for institutional delivery, many women 

preferred to deliver at home. Inquired were made to understand the reasons. As per 

51 percent of the AWWs, women believe that better care can be availed at home, 

28


whereas 43 percent each feared going to hospital or of injection, needle, equipment 

at the hospital, had fear of doctor/nurse and also thought that home delivery was 

cheaper, and hospital delivery was costly. Shyness of going to a doctor for delivery, 

lack of understanding about the importance of institutional delivery also contributes 

to reasons for preferring home delivery. Other reasons put forth by up to five percent 

of the AWWs were related to not believing in AWWs, unavailability of transport facility 

on time, and perception that hospital was for complications during delivery 

(Table A25). 

AWW’s clientele 

AWWs were asked about a brief description of their last case, to get an idea of the 

spectrum of services that they provide. On average, the last case availed services from 

the AWW around 79 days ago, ranging between one day to one year. Several AWWs 

mentioned that their last case was before months ago. More specifically, 42 AWWs 

mentioned about their last case more than 60 days ago. The average age of the last 

case of AWW worked out to be 25.4 years with an average of 1.2 children. Fifty-two 

percent of the AWW cases were schedule caste/schedule tribe, while 6 percent 

belonged to other backward caste group. The main reasons for the interaction 

between AWW and their last case was for immunization (41 percent), registration of 

pregnancy (31 percent), to get BPL card (21 percent), and to collect medicine for fever 

or vomiting (16 percent). Women also contacted the AWWs to get advice about 

nutrition (13 percent), advice about place of delivery (12 percent), information 

regarding sterilization or antenatal care/check-up. Another up to only 7 percent of 

the AWWs were contacted for procuring IFA tablets, Mala D or condom, post natal 

care, or as they did not get money after delivery (Table A26). 

Out of 17 women accompanied for delivery by the AWWs, three cases were 

accompanied for delivery within 20–30 days and another 3 cases between one to two 

months. The rest of the cases were accompanied for delivery before 2 months. On 

average, it is now almost over 3.5 months (108.6 days) since when AWW last 

accompanied a woman for delivery. Only six percent of the AWWs (53 percent among 

those who accompanied a case), stayed with JSY beneficiary at the place of delivery 

for an average of 13.9 hours. In two-thirds of the cases, AWW stayed back at the 

place of delivery for less than a day, while another eleven percent stayed with the 

women for two days or more (Table A27). 

29


Networking of AWW 

Under the NRHM, AWWs 

Figure 3.3: Network of AWW with stakeholders 

network with various 

stakeholders, meet them 

frequently and discusses 

ANM 

100 

/ carry out several health 

related activities. AWWs 

PRI 

87 

were asked about the 

pattern of networking, 

SHG 

82 

activities carried out in 

collaboration, and 

PHC staff 

71 

whether AWWs found the 

various stakeholders 

Village mandal 

50 

supportive. The results 

presented in Figure 3.2 

Block facilitator 

29 

show that all AWWs met 

ANMs, followed by 

Health 

and sanitation committee 20 

panchayat members (87 

percent), self-help group 

NGO staff 5 

(82 percent) and PHC 

staff (71 percent). Every 

second AWW mentioned 

0 20 40 60 80 100 

about meeting village mandals, and 29 percent met block facilitators. There seems to 

be lesser interactions with village health and sanitation committee and hardly any 

contacts with the NGO staff (20 and 5 percent respectively). 

As per frequency of meeting of AWW with the stakeholders, one-third of the AWWs 

met ANM at least once a week, and 23 percent met fortnightly. The remaining 43 

percent of the AWWs meet ANM monthly or less frequently. With other stakeholders, 

including PRI, health and sanitation committee, SHG members, NGOs, PHC staff only 

up to one-sixth of the AWWs met at least once a week. In the case of block facilitators 

and village mandal, meetings were less frequent and weekly meetings were reported 

by only 9 and 4 percent AWWs respectively (Table A28). 

The AWWs were asked when they last met the stakeholders from the date of interview. 

The analysis reveals that among those who met the stakeholders, on average, AWWs 

last met ANMs around 11 days ago; SHG members and Panchayat members around 17 

days ago, health and sanitation committee nearly 20 days ago; village mandal and 

PHC staff (around 22-25 days ago), followed by and block facilitators before 39 and 

49 days respectively. 

AWWs work in close collaboration with the ANMs to enhance the utilization of 

immunization services (74 percent), followed by less than one-fourth who organize 

health days, motivate pregnant women for antenatal check ups, provide health 

awareness to the community, mobilize infants for nutritional supplements, ensure 

payment of cash assistance to JSY beneficiaries, and take care of antenatal mothers. A 

few AWWs said that together, they provide curative care, FP services, school education 

30


and promote sanitation and hygiene. AWWs also get guidance from ANMs and help in 

administration work. Similar activities are reported with the PHC staff, block 

facilitators, village Panchayat and NGO staff. 

AWWs work with block facilitators, NGO staff, health and sanitation committee and 

self-help group to provide health information to the community, and organize health 

days/camp and enhance utilization of immunization services. AWWs get their 

medicine supply replenished from the block facilitators. They work with PHC staff to 

ensure payment of cash assistance, collaborate with SHG, NGO staff, village mandals, 

block facilitators to motivate people for saving money under saving scheme, and 

promote sanitation and hygiene with health and sanitation committee (50 percent), 

village panchayat members, NGOs and village mandals. Eleven to 29 percent of the 

AWWs said that they get help in administration and registration work and guidance to 

overcome problems from the village panchayat, NGO staff, village mandal, SHG and 

block facilitators. 

Almost all the AWWs opined that the stakeholders except Health and Sanitation 

Committee, PRI and SHG members were supportive. 

The Role of other Stakeholders 

Under the NRHM, officials of various levels including block officials, village panchayat, 

NGOs, SHG, health department, and CBOs have specific roles and responsibilities in 

the implementation of ASHA intervention and JSY. When asked, in most cases AWWs 

were not aware about the role of these stakeholders. For instance, the role of NGOs, 

CBOs, block officials, PRI and SHG in the execution of the ASHA component and JSY 

was not known to 65, 59, 54, 22 and 20 percent of the AWWs respectively 

(Table A29). 

It is encouraging to note that AWWs knew about the role of Health Department in 

implementation of JSY. As per 36 percent of the AWWs or less, the department was 

involved in various activities including providing medicines/drug kits (31 percent), 

immunizing of children, arranging money, organizing village health day, creating 

awareness of JSY among community, and motivating people for institutional delivery. 

Less than 7 percent were involved in birth and death registration, motivating AWWs, 

provide supplies, monitored work of AWW, training of AWWs, giving treatment to 

women, and maintained hygiene and sanitation in the village. Besides, the health 

department motivated solved problems of AWW, gave BPL certificate, and was running 

saving scheme. 

Panchayati Raj Institute 

According to one-fourth of AWWs, Panchayat served the village by building roads, 

drainage lines, and water facilities and 15 percent AWWs said that PRI played a role in 

maintaining sanitation in the village. PRI members created awareness of JSY among 

community, registered birth and death, provided BPL certificates, organized village 

health day, solved problems of AWWs, monitored their work, ensured payment of 

widow pension, trained AWWs and motivated people for institutional delivery. 

31


NGO/CBOs 

NGO’s role was not known to the Anganwadi workers. Less than 2 percent of the 

ANMs mentioned that NGOs were involved in solving problems, creating awareness of 

JSY among community and training and motivating AWW from time to time. In 

qualitative component of the study also NGOs role was tinted as nil (Table A29). 

Block Officials 

In Himachal Pradesh, the block officials were involved in arranging money (12 

percent), creating awareness of JSY among community, help in training of AWW, in 

organizing village health day (8 percent), and solve problem of the AWW. A few (less 

than 2 percent) of them helped in immunization of children, building roads/drainage 

lines/water facilities, and registration of birth and death. 

Incentives Received as AWWs 

All the AWWs interviewed were asked details about the cash incentive money received 

by them. The study reveals that 18 percent of the respondents did receive some cash 

incentive money. Among these 82 percent of the AWWs each received money for 

immunization of children. Only 11 percent AWWs got money for attending JSY 

beneficiary and four percent for family planning work. ANM/FHW of sub-centre (71 

percent), MO CHC/PHC (8 percent), and CDPO office (4 percent) gave the cash 

incentive money to AWW. AWWs were asked about the amount they received for their 

last beneficiary case. 

Only 15 (10 percent) AWW received money for their last beneficiary case who could be 

child’s mother for immunization or JSY beneficiary. On average, the amount received 

was Rs. 312.5 (Table A30). Out of 150 only one AWW received money for attending JSY 

beneficiary and 58-62 AWWs for immunization of children. The mean amount received 

for attending JSY beneficiary was Rs. 25 and for immunization of children, it was Rs. 

32–37 (ranging between 25 and 200). Only one AWW received payment of Rs. 25 for 

providing other services (Table A31). 

AWWs got the payment for the last case at sub-centre (71 percent), CHC/PHC (13 

percent), followed by the Anganwadi (4 percent). 

The study reveals that nearly 21 percent of the AWWs got the payment immediately, 

on the same day, whereas the remaining got the payment within a month (33 percent) 

or after more than a month (42 percent) for the last case. Few AWWs did not perceive 

(or reported) that they received some payment on monthly basis when asked earlier. 

Five AWWs said that they did not got the cash incentive on time due to lack of budget 

at the centre (n=2), or for the need of approval for the payment (n=1) and as AWW 

mentioned, there is lack of clarity on JSY. 

The study reveals that of the 91 AWWs (61 percent) who had received some cash until 

now, one-third AWWs were satisfied (15 percent) or somewhat satisfied (18 percent) 

with the cash incentive received under the scheme because they served the 

community (11 percent) had opportunity to work within the village (11 percent), they 

received money (8 percent) and got the opportunity to learn many new things and 

32


work within the village., 63 percent of the AWWs expressed that they were not 

satisfied with the cash assistance as the salary was not adequate for the work they did 

(53 percent), did not get the money due (21 percent), payment was delayed (23 

percent), or that some AWWs were favoured and they got money even if activities were 

not done (Table A32). 

Supervision and Monitoring of AWW 

Each of the AWWs was asked about the supervision and monitoring process. The 

study reveals that 96 percent of the AWWs maintained records and registers, related 

to immunization of children (92 percent), followed by 60 percent of the AWWs each 

maintaining child registration, nutrition/growth-chart register and drug register. Birth 

and death registration (54 percent), ANC (name, address, EDD, registration, weight) 

register (40 percent), household survey (36 percent), and delivery case record (23 

percent), were also maintained by AWWs. Besides some AWWs maintained adolescent 

girl’s registration, family planning, stock register, pre school education register, SHG 

group register, and sanitation register (Table A33). 

The average time taken to maintain and keep the records updated was 5.5 hours per 

week ranging between 1 hour and 24 hours. Twenty-nine percent of the 144 AWWs 

records to the health department. Eighty-four percent of the AWWs said that they 

submitted the report to Anganwadi supervisor, CDPO (12 percent) and 4-7 percent 

submitted reports to ANM/MO PHC. 

Mainly Anganwadi supervisor (93 percent) and CDPO/DPO (9 percent) checked 

records maintained by AWWs. ANM and MO PHC checked records of only a few AWWs 

(7 percent or less). Most (95 percent) of the AWWs said that they did receive some 

feedback from the supervisors. 

All the AWWs interviewed were asked if any district or block officials visited the place in 

the past 3 months. Twenty-eight percent (n=42) of the AWWs said that no one ever 

visited since they started working and 49 percent (n=74) were not visited by any 

supervisor in past three months. These 116 AWWs were from all the six study blocks 

majority being from Gagret block (n=32) and Tissa (n=21). From the other four blocks 

14-18 AWWs mentioned that senior supervisors had not visited them in three months 

or never before. Senior officials visited 22 percent of them – (21 percent when AWWs 

were present but 1 percent when AWW was not there). The study reveals that only 18 

percent of the 108 AWWs visited by senior officials were informed in advance about the 

visit of block or district officials. AWWs need to be informed in advance about officials’ 

visit. Such visits with prior intimation are more productive in enhancing the quality of 

work. 

Opinion about the JSY Component 

All the AWWs were asked about their understanding of the objectives of government in 

implementing JSY, and about their views regarding future training needs. The study 

shows that 44 percent of the AWWs knew that the objective of the government in 

focusing on the JSY component is to promote institutional delivery and 51 percent of 

the AWWs mentioned providing benefits to poor people. Twenty-five to 35 percent of 

33


the AWWs mentioned reducing the maternal and child mortality, creating awareness 

about health in the community and improving immunization coverage. Another 17-19 

percent mentioned improving mother’s health and safe delivery to save the child. 

Others (less than 11 percent) mentioned about social development, population control, 

tuberculosis control and improving mother’s health through ANCs (Table A34). 

Most of the AWWs interviewed opined that overall their knowledge and skills as AWW 

worker were well utilized (91 percent) or at least somewhat utilized (9 percent). 

Moreover, 69 percent of the AWWs thought that they required more training. Further, 

most (69 percent) of the AWWs thought that JSY is useful mainly as poor people get 

cash benefits, women get health related information (15 percent) or poor women can 

have institutional delivery. Fifty-three percent of the AWWs said that now most of the 

people are aware of JSY and avail its benefits, while 14 percent said that 40–70 

percent in the community avail benefits of JSY. 

Additional services Of the 31 AWWs who suggested additional services, said that they 

would like to ensure that all eligible women have BPL card, ensured advance money 

for ANC, and give necessary aids/medicines to the poor women. Further they would 

ensure that women get health related information, first aid services, and publicize JSY 

(Table A34). They also said that they should have a vehicle, and would like to build 

latrines for poor people. 

79 percent of the AWWs gave suggestion for improving JSY. They suggested that cash 

assistance should be increased (66 percent), need and more information provided to 

JSY beneficiaries (62 percent) and visit of officials/doctors/nurse to explain JSY to 

people in the village (42 percent). The scheme should be more propagated on TV, in 

newspapers, camps and rally, more incentives for sterilization cases, availability of a 

lady doctor, dai training, providing dai kit for AWWs, and improved facilities. Others 

(8 percent or less) suggested for good behaviour with women at the place of delivery, 

arrangement of van/transport, IEC campaign to deal with myths and misconceptions, 

joining letters to be given soon, and practical training for AWWs should be imparted 

Difficulties and Challenges Faced by AWW 

Only one-third of the AWWs said that they have no problem in implementing JSY. The 

main difficulties faced by other AWWs include women who are not willing to go for 

institutional delivery (44 percent), opposition from community to institutional 

delivery, illiterate people, and family members of the women (26–33 percent), and 

women not willing to take IFA tablets. One-fifth of the AWWs complained that their 

husband/family disliked the job, and that their work load is too much as compared to 

their salary which is low. Besides, JSY beneficiaries who do not receive payment on 

time complain to the AWWs (12 percent). Poor accessibility in the area, seniors did not 

allow them to work and cases motivated by them were registered by ANM are some of 

the other challenges. Yet other challenges, like ANM not allowing them to work 

without joining letter, was also put forth by AWWs (Table A36). 

34


To sum up, AWWs were middle aged, educated and representative of community. On 

average, AWWs had been working since 9 years. Only 29 percent of the AWWs were 

aware about ASHAs and the first source of information about the ASHA intervention 

for AWWs was through ANMs and health personnel. Training of AWWs was under 

different programme for an average of 5.1 days and was mostly held at AWW centre, 

balbhavan or nursing training centre. AWWs did appreciate the training including the 

trainers and training methods as good and useful. 

Among all, fifty percent of the AWWs knew about ANC and newborn care and they 

scored eight or more out of 10 points. However, awareness about danger signs was 

low and hence AWWs are not likely to detect cases prone to maternal and/or neonatal 

mortality. AWWs attends immunization session, organizes health days at AWW centre 

and accompany ANM and women for delivery. Drug kits were available and utilized by 

the AWWs in Himachal Pradesh. 

Majority of the AWWs knew about JSY and they came to know about the JSY for the 

first time from ANM, medical officer, trainers, and other Anganwadi workers and 

CDPO. AWWs and AWWs along with the community need to be prepared for arranging 

prompt referral services and transferring a woman quickly to the place of delivery. On 

average, the time taken to arrange for the transport and reach the institution is 

around 77 minutes. There is no clear guideline regarding the ways to handle cases 

when a woman goes to her natal place for delivery in another village. 

According to AWWs, women prefer home deliveries, as there is better care at home 

and due to various fears of doctors, nurses, and hospital setting, home deliveries are 

cheaper, shyness, lack of understanding about the importance of institutional 

delivery, as well as unavailability of transport facility on time. 

AWWs do provide constellation of services and network with the various stakeholders 

including ANMs, PHC staff, self-help groups, Panchayat members, block facilitators, 

village mandals, and to some extent with the village health and sanitation committee 

to implement JSY. AWWs also spend 5.5 hours every week in preparing and updating 

various registers and AWW’s work is mostly monitored by the Anganwadi supervisors. 

35

CHAPTER 4 

BENEFICIARIES OF JSY IN HIMACHAL PRADESH 

In the rapid assessment of JSY, beneficiaries were interviewed to understand their 

background, source of information and awareness about JSY, and the kind of support 

received from Anganwadi workers and ANM. The study also tried to examine if the 

process of claiming benefits under JSY was simple, nature of difficulties faced in 

availing services/benefits, and satisfaction of JSY beneficiary with the implementation 

of the scheme and cash assistance. Chapter 4 presents the findings from interviews 

with 237 JSY beneficiaries from three districts of Himachal Pradesh. The study meant 

covering at least 40 JSY beneficiaries from each of the six study blocks. However, in 

four blocks of Amb, Mashobara, Tissa, and Sunni due to non-availability of JSY 

beneficiaries only 34–36 of them could be interviewed. To balance out, in Pukhari 

block 51 JSY beneficiaries and in Gagret 46 beneficiaries were interviewed. Out of 237 

JSY beneficiaries, 124 had delivered at home and the remaining 113 had institutional 

delivery. 

Background Information of JSY Beneficiaries 

The profile of JSY beneficiaries shows that the mean age of the women was 23.6 

years. Most (92 percent) of the women were aged between 20 and 29 years. Twelve 

percent of the JSY beneficiaries in Himachal Pradesh received no formal education and 

another 23 percent had studied only up to primary or 5 th grade. Only 11 percent had 

studied above higher secondary level. It is notable that 18 percent of those who 

delivered in an institution as against 50 percent of those women who delivered at 

home were less educated (up to primary) and had no formal education. 

Most of the beneficiaries (98 percent) were Hindus and the remaining two percent 

were Muslims. Further, the study found that 60 percent of the beneficiaries belonged 

to either scheduled caste or scheduled tribe and 5 percent belonged to other 

backward classes. The beneficiaries represent lower income group with mean family 

income calculated to be Rs. 1,635 per month. On an average, the beneficiaries had 

1.4 children (on an average 0.7 each of sons and daughters) (Table J1). 

Awareness about JSY 

All JSY beneficiaries were asked about 

their awareness. The study shows that 51 

percent of the beneficiaries heard about 

the scheme during pregnancy and 27 

percent after their delivery. Only 14 

percent of the beneficiaries knew about 

the scheme before being pregnant and 

eight percent did not remember when 

they heard about the scheme (Figure 3.1). 

During 

pregnancy 

51% 

Figure 4.1: Time when the beneficiary 

heard about the JSY 

After 

delivery 

27% 

Cannot 

say/do 

not 

remember 

8% 

Before 

pregnancy 

14%


ANMs were the main source of information about JSY (48 percent), 36 percent 

mentioned about Anganwadi centre/workers and 23 percent heard about JSY from 

doctor. Rest all including hoardings at SC/PHC, radio/TV, relatives, gram panchayat, 

pamphlets, other users of JSY and neighbours were each mentioned by 5 percent or 

less of the JSY beneficiaries. Seven percent did not remember from where they heard 

about JSY (Table J2). 

Each of JSY beneficiaries was asked about what they heard about JSY. Analysis of their 

responses shows 44 percent of the beneficiaries heard that JSY is for getting money, 

for the benefit of the child (38 percent), for intake of nutritious food (32 percent) and 

30 percent heard that JSY was for promotion of institution delivery. Analysis further 

reveals that only 18 percent each of the beneficiaries heard that the scheme is for 

benefit of mother and to provide free institutional delivery services for poor women 

with some financial assistance. Only eleven percent of the beneficiaries mentioned 

about promoting family planning, while 2 percent or less mentioned about stabilizing 

population growth, or scheme for poor family. One-tenth of the beneficiaries did not 

know what they heard about JSY. 

Process of Registration under JSY 

Registration under JSY is essential to avail the benefits, and more so for monitoring of 

the activities. The data shows that only 13 percent of the health functionaries 

approached the beneficiaries, while 68 percent beneficiaries had themselves 

approached somebody in the health department for JSY registration. ANM/FHW (63 

percent), doctors (15 percent) and anganwadi worker (14 percent) registered the 

beneficiaries. Others registered four percent of the beneficiaries and LHV registered 

only one percent of the cases. Three percent of the beneficiaries did not recollect who 

registered their name for JSY. Only one-fifth of the JSY beneficiaries were registered 

in 1 st trimester, 34 percent got registered in the second trimester, and 19 percent in 

3 rd trimester, and as high as 20 percent were registered under JSY after delivery. 

Seven percent did not know at which stage of pregnancy they got registered for JSY. 

Regarding the place of registration in Himachal Pradesh, the sub-centre (54 percent) 

played a major role in registering JSY beneficiaries followed by PHC (20 percent) and 

Anganwadi centre (11 percent). Some six percent were registered at CHC and four 

percent at district/sub-district hospital. Two percent or less each got registered at 

the home and at panchayat. A closer look at the analysis reveals that a quarter of the 

women who delivered at home were registered at CHC and Anganwadi centre as 

against nine percent among those who delivered at an institution (Table J3). The JSY 

card is yet to be introduced in Himachal Pradesh and hence queries related to that 

were dropped from the analysis. 

Utilization of ANC Services by JSY Beneficiaries 

The beneficiaries were asked about the antenatal services utilized by them under JSY. 

The study reveals that 90 percent of the women realized that they were pregnant 

within first trimester and most of them (91 percent) confirmed pregnancy through 

testing (Table J4). In 30 percent of the cases, health personnel contacted the women 

during pregnancy, while 61 percent of the beneficiaries themselves contacted 

somebody from the health department. Nine percent of the beneficiaries mentioned 

38


that no contact had been made. Among those who had contact with the health 

personnel, the first contact with the health institution was during 1 st trimester (70 

percent) or 2 nd trimester (29 percent). On an average, the first contact was made by 

3.3 months of pregnancy up to a maximum of 8 months and with median value of 3 

months. For majority of the antenatal women, the first contact was with doctor (54 

percent) followed by ANM (44 percent) and one percent each contacted LHV or 

Anganwadi worker. Health personnel advised most (97 percent) of the women for 

antenatal check-up (Table J5). 

Most (95 percent) of the JSY beneficiaries had availed antenatal check-up during 

index pregnancy. The study reveals that 26 percent of the women had antenatal 

check-up done during the index pregnancy within 2 months, 46 percent within 3–4 

months of pregnancy and 12 percent during 5–6 months. It is surprising that 14 

percent of the women had antenatal cheek-up done by 7 th month or later during 

index pregnancy. The study further reveals that, on an average, JSY beneficiaries had 

antenatal check-ups done for 3.7 times. Most (74 percent) of the women had 

antenatal check-ups done for 3 times or more. Majority of the women received 

antenatal care at the district/sub-district hospital (34 percent) or sub-centre (32 

percent), and 16 percent each at home and PHC (Table J6). It is noteworthy that 31 

percent of the women who delivered at home received antenatal care services at 

home, as against only one percent who had institutional delivery. The women were 

influenced by their husbands (76 percent), self (56 percent), or mother-in-law (51 

percent) to go for antenatal check-up. LHV/ANM/FHW or other family members 

influenced 15 percent each, while Anganwadi workers (11 percent), and doctors (7 

percent) also motivated women to go for antenatal check-up (Table J7). 

Husband (72 percent), mother-in-law (36 percent), and sister-in-law (17 percent) 

mainly accompanied the beneficiary for ANC visit(s). Mothers, brother/father/other 

males, sister, Anganwadi worker also accompanied the women for ANC visits. The 

analysis further shows that 11 percent of the women who delivered at home and two 

percent who delivered at institution had no one to accompany them for ANC visits 

(Table J8). 

Seventy four percent of the women incurred expenses for receiving antenatal 

checkups. The average amount spent during ANC period among those who have 

incurred expenses including doctors’ fees, laboratory test worked out to be Rs. 

1231.1 approximately. Among those who incurred expenses, women who delivered at 

hospital spent Rs. 1522.9 for antenatal care as against Rs. 688.1 among those who 

delivered at home. Thirty-two percent of the JSY beneficiaries said that they received 

cash assistance for antenatal care. On an average, those who received cash assistance 

for ANC got Rs. 500.0. 

In all, eleven women or (5 percent of the total JSY beneficiaries interviewed) did not 

avail any antenatal care services during index pregnancy, mainly as they did not find 

it necessary to go for antenatal care, or because of expenses involved and opposition 

from the family. 

39


Role of Health Personnel in Helping JSY Beneficiary 

JSY beneficiaries were asked 

and prompted about the help 

provided and advice given by 

health personnel, particularly 

for micro birth planning. The 

analysis presented in Figure 

4.2 shows that health 

personnel gave IFA tablets (69 

percent) to the JSY 

beneficiaries, helped in 

immunizing the newborn (51 

percent), registered birth of 

the newborn (48 percent), 

while 20 percent each 

followed-up women or 

accompanied women to ANM 

for antenatal check-up, post– 

partum visit (16 percent) and 

gave money for transport (15 

percent). Moreover, only 8 

percent health personnel 

Figure 4.2: Help provided by Health Personnel to 

JSY beneficiaries 

Providing IFA tablets 

Helped in immunizing the newborn 

Registration of birth of the newborn 

Did follow-up 

Accompanied to ANM for check-up 

Visited in post-partum period 

Gave money for transport 

Accompanied to hospital for delivery 

Arranged transport 

8 

6 

16 

15 

20 

20 

51 

48 

69 

0 20 40 60 80 100 

accompanied women to hospital for delivery and 6 percent arranged transport for 

them (Table J10). 

Similarly, in majority of the cases, the health personnel advised JSY beneficiaries 

about diet (68 percent), danger signs (44 percent), delivery care (55 percent), 

breastfeeding (61 percent) and newborn care (57 percent). There was opportunity to 

talk about family planning during and after pregnancy that was mentioned by 44 

percent of the beneficiaries. 

Role of Health Personnel in Micro-Birth Planning 

Micro-birth planning includes discussion and deciding the date of next check-up, 

place of next check-up, place of delivery, expected date of delivery, and place of 

referral, in case of complications. Prompting on each aspect of micro-birth planning 

showed that majority of the health personnel discussed the date of next check-up (78 

percent), while 73 percent of the women each had discussion about place of next 

antenatal check-up and expected date of delivery, followed by the place of delivery 

(63 percent). However, only 38 percent talked about the place of referral, if 

complications arise (Table J10). It is important to know about the date of expected 

delivery, place of delivery and place of referral for timely arrangement of transport, 

decision making in terms of place of delivery. This is especially true in case 

complications arise. 

Fifty-eight percent of the JYS beneficiaries were told by health personnel about four 

or more aspects of micro-birth planning, 11 percent were given half of the 

information, while another 16 percent were told either only one or two aspects of 

40


micro-birth planning. Fifteen percent of the JSY beneficiaries said that no aspect of 

micro birth planning was ever discussed. It is clear that the process of micro-birth 

planning has begun but there is a long way to go for pre-planning institutional 

delivery. 

Intention versus Actual Place of Delivery 

The respondents were asked about the place where they intended to deliver and 

about the ultimate place of delivery. Thirty-nine percent of the respondents intended 

to deliver in government hospital and the remaining 60 percent preferred delivery at 

home. Only one percent JSY beneficiaries preferred to deliver at private hospital/ 

private hospital accredited by the government. 

Talking about the actual place of delivery, 52 percent of the deliveries took place at 

home and 34 percent of the deliveries took place in district/sub-district hospital, 

while 7 percent delivered at CHC and PHC (Table J11). Six percent delivery took place 

at Private hospital/private hospital accredited by government. 

Motivation and Decision Making for Institutional Delivery 

Safety of the mother and child (77 percent), better access to institutional delivery 

within the area (30 percent), money available under JSY (26 percent), complicated 

delivery/health problem/white discharge (18 percent), and the support provided by 

Anganwadi worker (12 percent) or health personnel were the motivations for opting 

for institutional delivery. Four percent of the beneficiaries opted for institutional 

delivery because of previous experience of institutional delivery and 3 percent each 

(n=1) mentioned previous history of dead child or because of transport assistance 

available (Table J11). 

Husbands (89 percent), women themselves (74 percent), mother-in-law (53 percent), 

father-in-law (27 percent) and relatives/neighbour/users of JSY (20 percent) were the 

persons who finally decided for institutional delivery. Anganwadi worker/ SHG 

members, friends and ANMS also played a role in motivating for institutional delivery. 

It is revealing and surprising that 52 percent had delivery at home as against 60 

percent who intended to 

deliver at home. A shift can be 

noticed among eight 

percentage points (n=18) of 

the total JSY beneficiaries 

interviewed who intended to 

deliver at an institution but 

delivered at home. The 

analysis further reveals that 45 

Table 4.1: Intention versus actual place of delivery 

Place where last delivery of JSY 

beneficiary took place 


Intended place for 

last delivery 

Institutional 

At home 

32.5 (77) 

15.2 (36) 

7.6 (18) 

44.7 (106) 

40.1 (95) 

59.9 (142) 

Total 47.7 (113) 52.3 (124) 100.0 (237) 

percent of JSY beneficiaries were obstinate to deliver at home. That is, they delivered 

at home as per their intention (Table 4.1). 

The main reasons for preferring institutional delivery for the 36 JSY beneficiaries who 

shifted from home to institutional delivery were complications (58 percent), safety of 

41


mother and child (14 percent), as per motivation provided by relatives to go for 

institutional delivery (11 percent) and non-availability of TBA in the village (6 

percent). For three percent the reasons for preferring institutional delivery were more 

facilities at the institution, past due delivery date, and complicated delivery. 

On the other hand, 18 women who intended to deliver at 

an institution but delivered at home did so, as they did 

not have time to reach the hospital (50 percent), on 

account of poverty and opposition from family members 

(17 percent each), while 11 percent believed that they 

get better care at home. The other reasons for 

preferring home delivery mentioned by one case each 

were non-availability of transport facility, and related to 

dai as dai did not allow woman to go to the hospital, 

preferred home delivery by dai/dai easily available etc. 

(Table J13). 

This house constitutes one village a 

family of eight lives there very hard to 

access due to lack of road 

Impact of JSY on Institutional Delivery 

To check the influence of JSY on women, each JSY beneficiary was asked about their 

place of delivery for the last but one child. Out of the total 237 JSY beneficiaries 

interviewed, 100 women had two or more children. In other words, for the balance 

137 mothers this was the first delivery. Fifty-seven percent of the previous deliveries 

were at home. Of the total, 24 percent continued with institutional delivery and 46 

percent continued to deliver 

at home. Nineteen percent 

shifted from institution to 

home, while a shift from 

home to institution delivery 

has been noticed among 

only 11 percent of the total 

JSY beneficiaries in Himachal Pradesh (Table 4.2). 

Table 4.2: Shift in the place of delivery before and after JSY (Percentage) 

Particulars 

Place of delivery for last (JSY) child 

Institutional Home Total 

Place of delivery for last but 

one child 

Institutional 

24.0 (24) 19.0 (19) 43.0 (43) 

Home 

11.0 (11) 46.0 (46) 57.0 (57) 

Total 35.0 (35) 65.0 (65) 100.0 (100) 

Further analysis of the reasons among those eleven women who had delivered their 

previous child at home but preferred institutional deliveries now are due to multiple 

reasons including safety of the child (n=7), cash assistance under JSY (n=4), had 

health problem (n=3) and as motivated by AWW. Among nineteen women who had 

their previous child delivered at institution but now delivered at home, the main 

reasons for opting for home deliveries were that dai takes better care (n=6), no 

necessity of institutional delivery (n=5), home deliveries are cheaper (n=5), better 

care at home (n=4), lack of time to go to hospital due to emergency (n=4), dai does 

not allow to go to hospital (n=2) and preference for home delivery. 

Process of Arranging Transport 

Some of the major delays in accessing health services during delivery are related to 

time taken in recognizing the problem, arranging for the transport, travelling time 

and delay in getting services after reaching the ultimate place of delivery. JSY 

beneficiaries were asked about the details of their transport to the place of delivery, 

42


role of key stakeholders in arranging for transport and difficulties faced. Most (94 

percent) of the beneficiaries reached the ultimate place of delivery directly from home 

travelling an average distance of 22.4 kms from residence to the institution ranging 

from no distance to 200 kms. Only 27 percent of the women had to travel up to 10 

kms, while another 58 percent had to travel 11–20 kms. Fifteen percent of the women 

did not know about the distance travelled to the place of delivery. The modes of 

transport used to reach the ultimate place of delivery were car or jeep (84 percent), 

bus (13 percent), and walking (8 percent) while one percent mentioned about 

ambulance to reach the ultimate place of delivery (Table J15). 

Family members (93 percent) facilitated in arranging the transport. Anganwadi 

workers arranged transport for only 5 percent of the women. Panchayat members (3 

percent) and ANM/health worker played a minuscule role in arranging the transport 

facilities. Despite the programme interventions, only 16 percent of JSY beneficiaries 

mentioned that the arrangements were pre-planned. 

The average time taken to arrange the transport after deciding to visit the ultimate 

place of delivery was calculated to be 40 minutes, and in most cases it was up to half 

an hour. In few cases (n=9), it took between 1 and 4 hours in arranging the transport. 

Further, it took on average another 71 minutes to reach the ultimate place of delivery 

from the time the transport facility reached the respondent. The time taken to travel 

to the place of delivery in most cases (65 percent) ranged between half an hour to 2 

hours, while in ten cases it ranged between 2.5 hours to 4 hours. Overall, 12–16 

percent respondents did not know details about the distance travelled, or time taken 

in arranging the transport and reaching the place of delivery. 

The study reveals that on an average, the beneficiaries spent Rs. 528.6 on transport 

to reach the ultimate place of delivery. Forty-four percent of the beneficiaries spent 

more than Rs. 500 for transport while 37 percent spent between Rs 200 – Rs. 500. 

Fifty-three percent of the respondents said that they had money on hand to pay for 

the transport expenses (Table J15). The others took borrowed money from someone 

to pay for transport (59 percent), borrowed money from friends or relatives (23 

percent), took loan (13 percent) or borrowed money from neighbour. Thirty percent 

(n=33) of the women who used transport to reach the institution said that they 

received money for transport or were reimbursed later. Women said that they received 

Rs 544.3, on an average (Table J16). 

Difficulties Faced in Reaching the Place of 

Delivery 

Under JSY, it is envisaged that health personnel 

will provide a referral slip to the women for their 

easy access to place of delivery and help in case 

of complications during delivery. The study 

reveals that health personnel gave a referral slip 

to 17 percent of the JSY beneficiaries to help them 

access services. The study also reveals that 13 

percent (n=15) of the beneficiaries had some 

43 

How can a pregnant woman climb those 

paths even at 8 months


difficulties in reaching the health institution. In 53 percent of the cases, transport was 

not available immediately, while 47 percent each of the respondents mentioned that it 

was late in the night or that they did not have sufficient money. In seven percent 

cases, the beneficiaries complained that male members were not present in the 

household (Table J17). 

Persons Accompanying JSY Beneficiaries to the Health Institution 

The study found that 12 percent of the beneficiaries reached the place of delivery in 

the night between midnight and early morning. Their husband and mother-in-law 

each accompanied 86 percent and 59 percent of the women respectively, followed by 

other family members (43 percent), mother (20 percent), and neighbours (5 percent). 

Anganwadi worker, Dai/TBA, ANM/health worker, or government doctor each 

accompanied less than 4 percent of the women (Table J18). Two JSY beneficiaries 

mentioned that presence of Anganwadi workers facilitated in obtaining services like 

speaking to the medical health personnel and helped in expediting registration and 

other administrative processes. 

Quality of Services Available at the Place of Delivery 

An attempt was made to assess the quality of services at the place of delivery in terms 

of promptness in attending the delivery case, waiting time, person attending the 

delivery and average stay in the hospital. While 27 percent of the women did not 

know about the time taken to complete the registration process, others said that, on 

an average, it took 27 minutes ranging between one minute to two and half hours to 

complete the administrative process at the ultimate place of delivery. It took another 

35 minutes, on an average, as waiting time at the facility, ranging between 1 minute 

and 4 hours, until someone attended the JSY beneficiary. 

Seventy-nine percent of the deliveries were normal, as high as 18 percent were 

caesarean, and three percent were assisted deliveries. The doctor conducted only 55 

percent of the deliveries at the institution and ANM, nurse or LHV conducted another 

40 percent deliveries. Four percent women did not know who conducted their 

delivery. On an average, women were discharged within 52.6 hours after delivery. 

Further analysis showed that for normal delivery women were discharged in around 

30.4 hours (1.25 days), for assisted delivery in around 24.0 hours and for caesarean 

after nearly 5 days (119.0 hours) (Table J19). 

Payments Incurred for Services at the Health Centre 

It is important to understand the expenses incurred by women to avail certain 

services at the health institution. The study shows that 82 percent of the women had 

to pay for services at the health centre, mostly for medicines and fluids (91 percent), 

caesarean or operation charges (61 percent), accommodation (56 percent), laboratory 

test (53 percent), food charges (44 percent), paediatric care (33 percent), and 19 

percent paid for diagnostic or sonography test (Table J20). 

44


On an average, JSY beneficiary spent Rs. 3732.9 for the index delivery. 18% of the 

women did not know about the expenses incurred. It may be pointed out here that 

the expenses for the previous delivery were calculated to be on an average Rs. 1635.1 

(1823.9 for institutional delivery and 1453.1 for home delivery). 

Satisfaction with the Services at the Place of Delivery 

Most (97 percent) of the JSY beneficiaries were satisfied with the services available at 

the place of delivery because of cleanliness maintained at the health facility (85 

percent), good behaviour of the health staff and doctors (56 percent), and counselling 

about various aspects including breast feeding, immunization, follow-up visit, family 

planning, newborn care, diarrhoea management or because hospital provided good 

and sufficient services. A few others expressed dissatisfaction with the services, as 

facilities were not clean or adequate and the staff was rude (Table J21). 

Suggestions for Improvement of Institutional Facilities 

All the JSY beneficiaries who delivered in the institutions were asked for their 

suggestions regarding improvements needed in the health facilities so that one has 

better experience at the hospital. Most of the JSY beneficiaries were satisfied with the 

present facility. However, for further improvement, 12 percent of the women 

suggested that more doctors are needed so that they could spend more time with the 

patient, eight percent suggested for improved sitting arrangements, and 6 percent 

felt that the treatment should be free or at low cost. Others mentioned about good 

and courteous behaviour of doctors and health staff, and clean bathrooms and toilets. 

A few women (1-2 cases) mentioned about provision of good quality medicine, more 

wards in the hospital, adequate number of beds, more cash assistance, and that 

hospital should provide nutritious food (Table J22). 

Decision Making Process of Deciding for Home Delivery 

The women who delivered at home were asked if there was any discussion and 

consideration for institutional delivery. Fifty-nine percent of the women had 

discussed institutional delivery as an option, but still opted for home delivery mainly 

because of better care at home (32 percent), poverty (26 percent), fear of doctor or 

nurse (24 percent), thinking that there is no need of institutional delivery (22 

percent), fear of going to hospital (19 percent), preferring home delivery (19 percent) 

that are cheaper (16 percent), shyness (13 percent), due to notion that dai takes 

better care at home (11 percent) and fear of caesarean section/stitches (11 percent). 

A few of the women preferred home delivery as they would consider going to hospital 

only if complication arise or only in case of emergency, lack of time to go to the 

hospital, non-availability of transport on time (4 percent), first delivery is preferred at 

home, and because dai did not allow women to go to the hospital (Table J23). 

Apart from self, husbands and mothers-in-law decided for home delivery, instead of 

institutional delivery. Father-in-law and relatives also decided for home delivery. 

Further probing reveals that the majority (55 percent) of the JSY beneficiaries who 

delivered at home had received information about the benefits of institutional 

delivery. Women were explained mainly by ANM/LHV/Nurse, and in some cases by 

doctor, friends, relatives and TBA that institution delivery would be safe for women 

45


and child, there could be better services at the hospital, and that women would 

receive cash assistance. Motivators also explained about follow up check ups and free 

medicine. Thirteen percent did not respond to these queries. 

Moreover, 31 percent (n=38) of the beneficiaries who delivered at home were aware 

of availability of additional Rs. 200 assistance in case of institutional delivery (Table 

J23). In addition, nearly 44 percent of the women who delivered at home experienced 

complications just before or during delivery such as excessive labour pain (66 

percent), excessive white discharge (46 percent), obstructed labour (16 percent), 

prolonged labour and health problem (11 percent each), and seven percent each 

experienced premature labour and breech presentation. Two percent each of the 

women who delivered at home experienced excessive vaginal bleeding and problem 

in uterus (Table J23). 

Persons who Assisted Delivery at Home and Views about TBA 

Of the 124 home deliveries, the TBA conducted 87 percent of the deliveries, while 27 

percent were conducted by friends or relatives. LHV/ANM/nurse and doctor assisted 

eight and two percent of the home deliveries respectively (Table J24). 

All the JSY beneficiaries were asked to give opinion about the role of TBA in providing 

all necessary midwifery services. Twenty-nine percent (43 percent who delivered at 

home against 13 percent who had institutional delivery) of the beneficiaries opined 

that TBA/dai can provide all the necessary midwifery services, as they are easily 

accessible (71 percent), know better about the cultural practices (43 percent), charge 

less money (37 percent), women feel more comfortable with TBA (22 percent) and 

have been traditionally conducting deliveries. Seventy percent of those who delivered 

at home said that TBAs are easily accessible (Table J25). 

Dynamics of Delivery at Home 

All JSY beneficiaries interviewed were asked about reasons 

why women prefer to deliver at home despite cash 

assistance paid under JSY. The major reasons for not 

preferring institutional delivery was poverty (24 percent), 

shyness of going to a doctor for delivery (14 percent), 

home deliveries are cheaper (13 percent) and 12 percent 

each mentioned about fear of doctors/nurses and clinics 

located at far off places. Nine percent mentioned fear of 

caesarean section, six percent each said that dai takes 

better care while assisting delivery or dai opposes to go to 

the hospital, prefer home delivery by dai, false medicines 

are used which cause the child to die. Five percent or less 

Delivered at home due to 

inability to climb to the road 

mentioned about lack of awareness of JSY, lack of understanding importance of 

institutional delivery, women believed that they got better care at home, if doctor says 

everything is normal then prefer home delivery and opposition from family members. 

Few mentioned that women deliver at home due to unavailability of family members 

on time, bad roads, lack of time to go to the hospital, staff is not cooperative, lady 

46


doctor not available in the hospital, no proper care at the hospital, nobody at home to 

accompany, or have to stay many days at the hospital (Table J25). 

Who Prefers Delivery at Home? 

Further analysis was undertaken to ascertain the reach of health functionaries, 

particularly AWWs, and ANMs to the beneficiaries, and utilization of ANC services and 

JSY by women who delivered at home versus those who delivered at an institution. 

Caste wise break-up shows that between 46–67 percent of the women belonging to 

different castes delivered at home (Table J26). The average monthly family income of 

the women who deliver at home was Rs 1453.1 and of those who had institutional 

delivery was Rs. 1823.9 only. 

The study showed that ANMs and LHVs have made efforts to contact women, who 

delivered at home, during various stages of pregnancy: first to register them (33 

percent home vs. 27 percent institutional deliveries), then to motivate them for 

antenatal check-up (26 percent) and to register them for JSY (11 percent) (Table J28). 

However, only two percent women were accompanied by AWW for ANC visits. Thus, it 

can be said that the grassroots level health functionaries are reaching this group only 

to some extent to motivate them for ANC and institutional delivery. 

Despite the motivation by ANM and AWW, the utilization of ANC services is low 

among women who delivered at home as compared to those who delivered in the 

institution. A higher proportion of women who delivered at institutions reported 

contact with health system in 1 st trimester (80 percent institution vs. 62 percent 

home). Similarly, with respect to antenatal check-ups done for 3 times or more (82 

percent institution vs. 66 percent home), expenses incurred for antenatal checkups 

(80 percent institution vs. 56 percent home), and average money spent on ANC (Rs. 

1522.9 institution vs. Rs. 688.1 home) home delivery cases exhibit low utilization 

(Table J29). 

Regarding utilization of services, the women who registered at home were from 

remote rural areas, had limited access to district/sub-district hospital. The source of 

services for women who delivered at home remains to be CHC, PHC or sub-centre. 

The study reveals that utilization of sub-centre in Himachal Pradesh is high. The 

study shows that these sub-centres need to upgrade the service component and 

facilities in the remote rural areas to attract women for institutional care. The study 

reveals that though health department is reached the women at home, they are did 

not come forward for institutional care. Some other factors including cultural and 

social influences need to be probed further. Difficult terrains definitely make it 

difficult for women to access health services. 

Mode of Payment and Difficulties Faced 

The study reveals that 76 percent of JSY beneficiaries received JSY cash assistance for 

delivery. 69 percent of the women who delivered at home as against 85 percent of 

those who delivered at institution received JSY cash assistance (Table J30). 

47


Ninety percent of the JSY beneficiaries who received the cash assistance received 

payment in one go, while 10 percent received money in instalment. Twenty-eight 

percent of the women received the cash assistance much later after delivery. Another 

17 percent said that they received the cash assistance within a week after delivery, 

while 45 percent received money before delivery. In 54 percent of the cases, ANMs 

gave the cash assistance to JSY beneficiary followed by CHC/PHC MO (23 percent), 

MHW and health centre (6 percent each). In some cases payments were made by 

Anganwadi worker, accountant, panchayat etc (Table J30). 

Forty-six percent of the women received cash assistance at CHC/PHC, followed by 

Sub-centre (30 percent). Fifteen percent of the women received cash assistance at 

home, only three percent each received cash assistance at the place of delivery or 

within village and two percent mentioned Anganwadi worker/Anganwadi centre. A JSY 

beneficiary received, on an average, approximately Rs. 587.8 during their last delivery 

ranging between Rs. 100 and Rs. 1200. 

The study reveals that 20 out of 181 (11 percent) JSY beneficiaries who received 

incentive for delivery reported that they faced difficulty in getting the money. It needs 

to be pointed out again that there are 

around 37 percent of the 

beneficiaries who received money 

late. They had to make several visits 

to get the money, received the 

financial assistance in instalments, 

did not get their payment when they 

needed money, or ANM had no money 

to provide the beneficiary with the 

cash assistance (Table J31). Forty-one 

percent of the total beneficiaries 

mentioned that the cash assistance 

received was not sufficient to meet 

Not 

sufficient 

41% 

Figure 4.3: Sufficiency of cash incentives 

received by JSY beneficiary 

Sufficient 

45% 

Somewhat 

sufficient 

14% 

the expenses of delivery. Others thought that it was sufficient (44 percent) or 

somewhat sufficient (14 percent) (Figure 4.3). 

Use of Cash Assistance Received for Delivery 

To assess the utilization of money by the women, they were asked ‘how did they use 

the money received under JSY?’ The analysis shows that 64 percent of them bought 

medicines/tonics for self and child and 62 percent used it for self-nutrition and 

fruits. Only nine and eight percent used money for medical expenses for delivery or 

had not spent money so far respectively. Only four percent said that they used money 

for the purchases of consumables for the family and one percent said husbands took 

away the cash incentive payment (Table J31). 

Appreciation of JSY by the Beneficiaries 

All the JSY beneficiaries were asked if they would recommend their relatives, friends 

or neighbours to be a JSY beneficiary. Ninety-two percent of the women were satisfied 

with JSY and answered in affirmative. They would recommend to relatives or friends/ 

48


neighbours to be beneficiaries under JSY. Women said they would recommend JSY 

because they did receive cash immediately on filling up form to meet expenses 

incurred at hospital, JSY was good, hospital provides good services, poor people 

receive help, free/cheaper delivery, receive good knowledge and education (Table 

J32). 

Complications during Delivery 

Out of 113 beneficiaries who had institutional delivery, 59 (52 percent) faced 

complications just before or during delivery. Sixty-one percent of the women who 

had complications perceived that they had excessive labour pain, followed by 22 

percent who complained of health problem or vomiting/feel uneasy/physically weak, 

19 percent obstructed labour, and 12 percent prolonged labour. Women also 

complained about various gynaecological problems (Table J33). 

Child mortality 

Four (1.7 percent) out of 237 JSY 

mothers reported that the newborn 

A 22 year old Hindu women literate upto 10 class 

and belonging to scheduled caste was pregnant 

child died. All the four children were 

for the first time. She took all the care during 

born in institution and died on the day 

deliver y, got registered herself as soon as she 

of birth. According to the mothers, 

learnt of pregnancy in the second month and 

newborns died because of fluid in 

went for more than five times for ANC care. She 

chest, incomplete growth (premature 

had a br eech presentation, and with labour pain 

delivery), child was born dead, and for 

she travelled 25 kilometres through hills to the 

one child mother did not know the 

district hospital along with her husband, mother- 

reason of death of the child (Table in-law, other family members and dai. It took her 

J34). All the mothers (n=4) were 2 hours to reach the place of delivery. She was 

young aged between 21 and 24 years, attended to within 5 minutes by the nurse and 

educated up to 8–10 class and were had a normal delivery. Bu t unfortunately she had 

Hindus. All four mothers had their a premature delivery and the baby died due to 

first ANC check-up during the first incomplete growth of child. 

trimester, while three mothers had 

three or more ANC check-ups. It is revealing that all of these children who died were 

born in an institution. None of the women reported problem in reaching the 

institution that was within 15-25 kilometres in three cases and 55 kilometres in one 

case from their residence. They hired a car/jeep or took a bus and were accompanied 

by their husband, mother-in-law, other family members and dai (one case). Travelling 

time was half an hour to two hours, while it was 3 hours in case of women who had to 

travel 55 kms. 

A 24-year-old, 9 th class educated Hindu Rajput women belonging to Adharghat, lost 

her male child immediately after her delivery. She took care during delivery, got 

registered herself as soon as she learnt of her pregnancy in the fourth month and 

went once for ANC care. When she had labour pains, she walked half a kilometre to 

the bus stand and went to the District Hospital 55 kms away from her residence in the 

bus along with her husband and mother-in-law. After travelling for three hours she 

had a normal delivery attended by a doctor. She delivered a baby boy who died on the 

49


first day of birth. She mentioned that the cause of death of her child was 

accumulation of fluids in chest and brain ‘dimag or chatti me pani bhar gaya tha’. 

To sum up, JSY beneficiaries are young and mostly those who had formal education or 

had schooling up to middle level. Sixty percent of JSY beneficiaries belonged to SC/ST 

and 5 percent to the other backward classes. The beneficiaries learnt about JSY during 

various stages of pregnancy, or sometimes only after the delivery from ANM or AWW 

and got themselves registered under JSY with the health personnel. As per the 

utilization of JSY, 70 percent reported their first contact during first trimester, and on 

an average, women had 3.7 antenatal check-ups during their index (JSY) pregnancy. 

Health functionaries have started discussing about micro-birth planning, and 58 

percent were told about four or more aspects (out of 5) of micro-birth planning. 

Unfortunately, 42% did not receive all information necessary to ensure early detection 

of complications and timely referral. It is challenging to make institutional delivery a 

preferred option due to a variety of reasons. Women preferred home deliveries 

despite cash assistance mainly because of poverty, shyness, home deliveries being 

cheaper, and fear of doctor/nurses. Besides, distance of the place of delivery, bad 

roads and difficult terrain made it hard for the women to opt for institutional delivery. 

Women believed more on dai with whom they were more comfortable, while facilities 

at the health centres were inadequate, in terms of manpower and materials. 

Only 15 percent changed their intention from delivering at home to an institution, 

while 8 percent intended to deliver at an institution but delivered at home. 

In Himachal Pradesh, JSY beneficiaries had to travel, on an average, 22.4 kms to reach 

the ultimate place of delivery. Women spent over 110 minutes to arrange transport 

and reach the ultimate place of delivery and another one hour after reaching the 

institution on registration administrative process and as waiting time until someone 

attended them. 

Seventy-six percent of the beneficiaries got payment and most received cash in one 

go (but much later) from the ANM or PHC/CHC doctor. JSY beneficiaries spent Rs. 

1231.1 during ANC period, Rs. 528.6 for transportation to the place of delivery and 

Rs. 3732.9 for delivery, against which they received an average of Rs. 544.3 for 

transport and Rs. 587.8 for delivery from the government as cash assistance. Such 

high amounts of money that women need to pay for delivery would certainly 

discourage poor women and their families to opt for institutional deliveries. 

50

Chapter 5 

Evidence of Success, Challenges and 


This study has attempted to understand the status of implementation of Janani 

Suraksha Yojana (JSY) and the processes adopted for its operationalization in the state 

of Himachal Pradesh. JSY beneficiaries were interviewed to assess awareness and 

utilization of JSY as well as adequacy and simplicity of the processes of claiming 

benefits. 

In addition to the programme specific results and findings, the research study as a 

whole yielded a richer understanding of the implementation of JSY and some ways to 

improve the programme. In Himachal Pradesh, JSY is being implemented in all 

districts, while ASHA component is yet to take off. As an alternative to this the state is 

utilizing the existing network of anganwadi centres. As per the study proposal the 

overarching themes that are crucial for successful implementation of the programme 

activities and its outcome are: 1) Programme management processes, 2) ANM’s 

contribution, 3) Cash assistance, 4) Increasing institutional (safe) deliveries, and 5) 

Community perceptions about JSY. 

Programme Management 

At the state level, NRHM Mission Director, and an officer on special duty provided 

overall guidance to implement the programme. At the district level, Chief Medical 

Officer and Deputy CMOH facilitated the implementation with technical assistance 

from the district nodal officers. Block Medical Officer and health supervisors at block 

level and Gram Sabha, Panchayat, Palikas, PHC/SC staff and ANM at the village level 

are the key implementers for ASHA intervention and JSY. 

While the state still has to identify and appoint ASHAs, it has moved ahead with the 

implementation of JSY. In the year 2006-07, 4185 JSY beneficiaries had been 

identified. For this, the state has used the existing network of AWW centers, which are 

active and also have linkages with the health department. 

Himachal Pradesh has involved the 8000 existing AWW centres along with the health 

workers to implement JSY. Upon selection of ASHA, it is planned to give the induction 

training to ASHAs in a phased manner. In Phase 1, 40 out of 75 blocks in the state 

covering all the districts would be selected. First round of training of 7 days would be 

implemented by March 2007 to June 2007. 

Some selected NGOs, CBOs, and SHGs were involved in implementing JSY. While the 

details of the scheme have been circulated from the state to the block level, the state 

has also initiated IEC activities for disseminating information about JSY through 

posters, pamphlets and wall paintings.


The process of decentralization of administration power is yet to start and district, 

block and village level stakeholders are yet to be involved in implementing ASHA 

intervention and JSY. Currently the untied funds are managed at block and PHC level. 

Similarly, in Himachal Pradesh, the process of accreditation of private institution is yet 

to be initiated. 

Middle aged women with some years of experience are working as AWW. Though they 

do not come under the health department, most of them were aware of the 

department’s role in implementing JSY. Their main source of information regarding 

JSY was the ANM and PHC staff. They were aware that the scheme was mainly for 

pregnant mothers belonging to BPL families. Their services to pregnant women were 

mainly related to supply of nutritious food, supply of IFA tablets and advice for 

antenatal check ups. Some of the AWWs received a cash incentive while for others it is 

still pending. AWWs do have linkages with the ANMs, PHC staff, self-help groups, 

Panchayat members, block facilitators, village mandals and village health and 

sanitation committee. 

ANM’s contribution to JSY 

In the absence of ASHAs, the role of ANMs in promoting JSY is crucial. The study 

indicates that ANMs do talk about JSY as 48 percent of the JSY beneficiaries had heard 

about it from the ANM. First contact for the JSY beneficiaries during their ANC period 

were ANMs for 44 percent. It was ANMs motivation that made 15 percent of the 

beneficiaries seek ante natal check ups. ANMs are involved in motivating the 

beneficiaries for institutional deliveries as against home delivery. And in case if the 

woman decides for home delivery, ANMs assistance for delivery is sought. Almost half 

of the JSY beneficiaries have received cash assistance as per the norm from the ANMs. 

While some of the ANMs had rolling money to give to the JSY beneficiary others did 

not however, ANMs hardly accompanied any women for delivery. Settlement of the 

payment was usually done after the delivery, only when the woman submitted all 

required documents. 

Cash Assistance 

Around three-fourths of the JSY beneficiaries had received cash assistance. Most of 

them had received the money in one installment, while 45 percent received the cash 

assistance before the delivery, others (25 percent) received it after the delivery and in 

28 percent cases it was much later. It can be said that a proportion of the JSY 

beneficiaries opted for institutional delivery because money was available under JSY. 

Women who received money were satisfied and did say that they would recommend 

others to avail the benefits of JSY. However, one fourth did not get any cash 

assistance or did not get their due amount. It is necessary that PRIs who are involved 

in the payment of cash ensure that women at least get their due payment including 

cash assistance for delivery and transportation on time. 

52



Increasing Institutional Delivery 

The main aim of JSY is to reduce maternal and infant mortality by promoting 

institutional deliveries, particularly amongst the poorest of the poor. The study 

indicates that to a great (60 percent) extend JSY beneficiaries intended to deliver the 

child at home, but 48 percent of the deliveries actually took place in the institution. 

Factors responsible for motivating women to opt for institutional delivery included the 

safety and better care of both the mother and child at the hospital, accessibility of a 

facility, on account of perceived health problems and complications experienced and 

also on account of money available under JSY and support provided by the Anganwadi 

worker and health personnel. Husbands play a key role in finally deciding for 

institutional delivery. Other family members like mother-in-law, father-in-law, 

relatives, other users of JSY have also played a role in motivation. 

Table 5.1: Motivational factors leading to institutional delivery as against intension, Himachal Pradesh 

Intended and 

delivered at 

Institution 

Intended to deliver at 

home but delivered 

in institution 

Total institutional 

deliveries 

N % N % N % 

Total 77 100.0 36 100.0 113 100.0 

For safety of the child 69 89.6 18 50.0 87 77.0 

Better care at institution for delivery 28 36.4 6 16.7 34 30.1 

Money available under JSY 26 33.8 3 8.3 29 25.7 

Had health problem 6 7.8 14 38.9 20 17.7 

Support provided by AWW 12 15.6 1 2.8 13 11.5 

Support provided by health personnel 5 6.5 2 5.6 7 6.2 

Previous child was born in an institution 3 3.9 1 2.8 4 3.5 

Availability of transport assistance 3 3.9 0 .0 3 2.7 

Previous complicated delivery 2 2.6 1 2.8 3 2.7 

Others 1 1.3 2 5.6 3 2.7 

A small percentage of women (n=18, 8 percent) who intended to deliver at an 

institution but still delivered at home was mainly because they could not reach the 

hospital in time (50 percent), due to extreme poverty or unavailability of transport (17 

percent). Women continue to opt for home delivery on account of various reasons 

which include their perception of better care at home, no need to go to the 

institution, shyness of going to a doctor for delivery and due to fear of doctors, 

nurses, stitches and caesarian sections. On account of these reasons it becomes very 

essential that the beneficiaries are satisfied with the services they receive at the 

hospital, or else they could deter them from coming to the hospital for delivery. 

Trained birth attendants are mainly involved in conducting the deliveries at home. 

They are preferred on account of their accessibility; they are considered to be 

knowledgeable, charge less money and women are comfortable with their services. 

Community Perceptions about ASHA and JSY 

As Himachal Pradesh has yet to appoint and train ASHAs, community members were 

not aware about ASHAs at all. However, the majority of the community was aware of 

JSY and its benefits. They had heard about the scheme either from the health workers 

and/or from the anganwadi workers. However, it was also expressed that the 

programme should be more widely publicized using multiple channels. This would 

enable the community members to entail the benefits from the scheme. 

53


Challenges 

Himachal Pradesh has implemented the JSY in the absences of the ASHA component, 

which the state presumed could be substituted by the existing network of Anganwadi 

centres bridging the gap between the beneficiary and the health facility. However, not 

all anganwadi workers were aware of the ASHA intervention. For instance only 29 

percent AWWs heard about ASHA. Further, AWWs have been functioning for some 

time and have received training on different aspects as per their role and 

responsibilities with AWW centre. If the department wants to involve AWWs in JSY they 

should be oriented on it first. Eighty-four percent of the AWWs had heard about JSY 

mainly from the health workers. Gaps do exist in their knowledge regarding maternal 

care and health. In Himachal Pradesh, the stakeholders thought that it is too early to 

evaluate the scheme. Some of the issues that the state needs to address for a 

successful implementation of JSY are as follows: 

Implementation of ASHA 

Under the GOI guidelines, the states were given the flexibility of modifying the 

guidelines as per the state’s need. While implementing JSY, the state has to consider 

the geographical feature in planning any of its programs. Therefore the state 

submitted a proposal for the criteria of selection of the ASHA. Considering the fact 

that an ASHA will be appointed for every 800 population that too in a state which is 

indicating a decreasing fertility rate, the authorities are concerned that the required 

services of ASHA in the small population would not give enough remuneration to her. 

Further, JSY beneficiaries in Himachal Pradesh are eligible for JSY services only if they 

are living below poverty line and they receive cash assistance for only up to two 

deliveries. 

The transition of responsibilities under JSY from the AWW to the ASHA should be done 

strategically, ensuring that the details of both the JSY and ASHA component of the 

scheme are known to all- in the absences of which there could be hurdles especially 

related to accountability and payments as even now in certain areas panchayat 

members had not heard about the schemes. Advocacy of the schemes should be done 

using multiple channels. As raised by a senior state officer, 

“When ASHAs start promoting institutional deliveries, the incentive money 

being paid to AWW would be given to ASHAs. Definitely AWWs would not like 

this. It would take time for them to understand and work in a coherent 

manner.” 

ASHA component is yet to be implemented at the grass roots level. Payment of ASHAs 

is a challenge to motivate them to work and sustain their interest. 

“As pointed out earlier, if ASHA in Himachal Pradesh will not get the benefit 

of JSY incentive money, how ASHAs will sustain? So that is the major 

challenge, otherwise we don’t see any problem. Except that once the 

54



incentive is withdrawn from AWW and has to be given to ASHA initially it will 

have some repercussions but it will phase out”. 

Involvement of AWW 

The presences of AWW in the system was capitalized by the state to implement JSY. 

However, their involvement in JSY has not been systematic as it can be in case of 

ASHAs, who have to undergo the initial training through module one. In case of AWWs 

it was observed that their knowledge regarding complications during pregnancy and 

delivery, danger signs, family planning, identification of risk factors, about breast 

care, newborn care is low and needs to be focused during subsequent rounds of 

training. Every sixth AWW did not know the period when newborns are most likely to 

die. Strengthening of such technical capacities would go a long way in contributing to 

the programme. Complete understanding of the scheme and its objective is lacking 

among the AWWs, which creates a barrier to the promotion of the scheme. Learning 

from the other states, it may be pointed out here that for training of ASHAs topics 

regarding danger signs, family planning, identification of risk factors and newborn 

care should be strengthened from the beginning. 

For instance, only 38 percent of the AWWs talked about the place of referral, if 

complications arise. It is important to know about the date of expected delivery, place 

of delivery and place of referral for timely arrangement of transport, decision making 

in terms of place of delivery. This is especially true in case complications arise. Only 

few of the JSY beneficiaries were fully informed for micro-birth planning, which is a 

key component of JSY for pre planning institutional delivery. 

ANMs participation 

As Himachal Pradesh has still not implemented ASHA scheme, knowledge and 

awareness about the same among the ANMs was almost negligible. The study 

indicates that ANMs do have contact with the JSY beneficiaries on different occasions 

during pregnancy. It is crucial to re-orient health workers and to utilize these 

moments to motivate the pregnant woman for institutional delivery. Though this gap 

should be filled by the AWW now and later by the ASHA, as a programme such 

opportunities should not be missed. 

Accessibility of Services 

The difficult terrain of Himachal Pradesh poses a major challenge regarding how to 

make the services accessible for beneficiaries. As most of the institutions are based in 

urban areas, there is a need to make it available in the interiors too. Lack of transport 

facilities to clinics, often located at far off places, also speaks volumes about the 

infrastructure facilities available in Himachal Pradesh. The terrain of HP is difficult and 

as observed by our field team every pregnant woman who intended to deliver in 

institution would have to walk down the hill tops or from their homes in the small 

lanes inaccessible to any vehicle and then take a vehicle to travel on difficult terrain to 

reach an institute. Given the situation, neither women nor their husbands or family 

members would prefer to travel at the expected time of delivery. 

55


Readiness of Facilities 

In the present scenario, a high proportion of PHCs and 

CHCs do not have the required health personnels and 

infrastructure in place. As per India Facility Survey-2005, 

only 13 percent have female medical officer, 63 percent 

had normal delivery kits, and only 25 percent had essential 

obstetric care drug kit. Only 22 percent of the PHCs 

conducted deliveries. 

A nodal officer shared the difficulties in monitoring 

because of difficult terrain in Himachal Pradesh. He 

explained, 

PHC no delivery facility 

“Difficulty is in monitoring the activities. In some sub-centre, there is only 1– 

2 health worker posted. They face many difficulties, because our terrain is 

difficult, households are far to reach, so communication problem is also 

faced”. 

Another nodal officer said, 

“Many of the family health centres in Himachal Pradesh are not able to 

provide services of institutional deliveries. Sub-centres are not equipped fo r 

institutional deliveries, only few PHCs and some CHCs have institutional 

delivery facilities. Some PHCs have vacancy of MO. In our district, 20 SCs are 

without any female health workers”. 

Ensuring Quality of Service in the Facility 

Increasing institutional delivery is a challenge, especially when functional facilities are 

sparse; this applies specifically to remote areas. Promoting institutional deliveries in a 

cultural setup where traditionally home deliveries are the norm, the task becomes 

more difficult. Negative experience of women with respect to the infrastructure as 

well as the behaviour of the health personnel further de-motivates them from 

utilizing services. A re-look at creating an enabling environment in the facilities for 

delivery related services are therefore the need of the hour. 

Cash Assistance under the Scheme 

The majority of AWWs had not received their due cash incentive under JSY in the 

absences of which it is difficult to ensure their participation. Cash incentive was 

received by only 18 percent of the AWWs. Among these, incentives for accompanying 

JSY beneficiary, was received by only 11 percent of the AWW. 

JSY beneficiaries received their cash assistance at varying times starting from during 

pregnancy to much later after the delivery. Some of the problems stated in receiving 

the money included repeat follow up request for the money, receiving the money in 

installments, payment not received when needed and delays in payment. The cash 

assistance received was not considered sufficient to meet their expenses especially 

taking into account transport related expenses. There is a lack of manpower to 

56



supervise, particularly with respect to checking the accounts and linking it with the 

performance, as realized by the state official, 

“We are not able to supervise properly. So many programmes are there and 

like this (JSY) are linked with money. We have to record properly, check properly. We need one more person who could check the accounts.” 

On average, women spent substantially more on antenatal care, transport and 

delivery than what they received under JSY. The study reveals that out of 237 JSY 

beneficiaries, 27 had no expenses during pregnancy and delivery nor did they receive 

any amount. Twenty-three percent of those who had home deliveries as against only 

three percent who had institutional delivery did not incur any expenses. In three 

cases, the beneficiaries received the exact amount they had spent. Hence, the net 

gain was balanced in case of these 13 percent beneficiaries only while 44 percent of 

the beneficiaries spent more than what they received under JSY. In the case of 43 

percent beneficiaries, the expenses were less than the amount they received under 

JSY. For those, who delivered at home, 17 percent have negative balance, yet on 

average they gained Rs. 174.8, while in the case of institutional delivery, women had 

spent an average of Rs. 2830.7 more than what they received. A beneficiary said, 

The expenses on transport are too high. Particularly during emergencies like 

labour pain, or during marriage or rain y seasons, the transporters here exploit people. They charged according to their own will. 

Table 5.2: Pregnancy expenditure as against the amount received by JSY beneficiaries, Himachal Pradesh 

Place of delivery 

Institution At Home Total 

Total 113 124 237 

1501 or more 

1001 to 1500 

501 to 1000 

251 to 500 

101 to 250 

1 to 100 

0 

-1 to -100 

-101 to -250 

-251 to -500 

-501 to -1000 

-1001 to -1500 

-1501 to -2000 

-2001 to -2500 

-2501 

Mean amount 

3.6 

1.8 

6.2 

8.0 

4.4 

0.0 

2.7 

2.7 

4.4 

8.0 

6.2 

7.1 

7.1 

5.3 

32.7 

-2830.7 

0.0 

0.8 

4.8 

49.2 

2.4 

2.4 

23.4 

4.8 

0.8 

8.1 

0.8 

0.8 

0.8 

0.0 

0.8 

174.8 

1.6 

1.3 

5.5 

29.5 

3.4 

1.3 

13.5 

3.8 

2.5 

8.0 

3.4 

3.8 

3.8 

2.5 

16.0 

-1258.2 

Forty-one percent of the beneficiary felt that the cash assistance received was 

insufficient to meet the expenses of hospital delivery. 

57




In the following paragraphs, an attempt has been made to present recommendations 

for improving JSY. These recommendations are based on the analysis of the findings 

and discussions with stakeholders. Findings are organized in three clusters such as 

policy; programme related and demand side issues. 

Policy 

1. The state needs to implement JSY by actively involving SPMU and DPMU. 

Setting up of such system and concretizing on the strategies would go a long 

way. Involvement and amalgamation of the district authorities with the 

community members through PRI members would be beneficial. An orientation 

training of the PRI members and reading material for them needs to be 

developed to facilitate their engagement at different levels. This should also 

take into account PRIs’ role in formulation of village health plans, use of untied 

funds, monitoring of the performance of ASHAs and other health personnel at 

grass roots level. 

2. The state needs to expedite the process of accreditation of private institutions 

and alternatively also utilize the services of private doctors to provide services 

through public institutions (PPP). 

Programme Management 

1. State proposal for implementation of ASHA scheme should be hastened. 

Having taken off with JSY, it will be beneficial. Although AWW are substituting 

they are doing it incompletely. 

2. State should plan and complete 1 st round of training of ASHAs and develop 

work plan for subsequent rounds of training of ASHAs with the involvement of 

district and block level officials associated with the programme. District health 

action plans should have detailed planning of ASHA and JSY intervention 

including activities and financial requirements to facilitate results based 

management. 

3. The study also clearly brings out that ANM’s role in micro-birth planning is 

minimal, each aspect of pregnancy including micro-birth planning, 

complications, danger signs, actions to be taken, referral etc. needs to be 

emphasized. ASHAs will have to be trained on detection of danger signs and 

sensitization of pregnant women on danger signs. A re-orientation training of 

ANMs needs to be planned on these aspects. 

4. ANMs and AWWs should play an important role in mentoring ASHAs towards 

family planning activities, since ASHAs would be in an excellent position to 

motivate women about family planning. 

58



5. Regular meetings with ASHAs at the block or PHC/CHC level for assessing 

performance and planning future activities need to be planned. These 

meetings could be utilized by the ANMs/LHVs and medical officers for 

reinforcing knowledge and learning in key areas, as in other LPS states. 

6. State should prepare a brief guideline for making the payment to ASHAs 

simple and timely, which need to be widely publicized in terms of 

entitlements. This could be monitored at the Panchayat level. Learning from 

other states, drug kits could be provided during the training of ASHAs that is 

yet to take place and ASHAs need to be explained about the contents of kit 

and their use. 

7. There is a need to upgrade the facilities at PHC/CHC and increase the 

number of functional sub-centres and institutions to meet the critical 

demand created for institutional deliveries. Normal deliveries can take place 

at PHCs and sub-centres, to lessen the caseload at the district and subdistrict 

hospitals. ANMs need to stay at the sub-centre. Presence of 

Anaesthetist is essential and needs to be ensured by the programme 

managers. 

8. The state needs to consider the suggestions of AWWs that reflect their needs 

and requirements. The AWWs suggested for increasing awareness among 

people about JSY, upgrading facilities to provide quality care, promoting 

family planning, and increasing pay of AWWs. 

Demand Generation 

Need for proper programme related communication has been observed at various 

levels: providers and stakeholders including community. The state government has 

introduced JSY in all the districts yet half of the community members were not aware 

of the programmes. Communication interventions are limited to disseminate 

guidelines in forms of circulars and some mass media activities in the form of wall 

paintings and hoardings. Radio and TV channels have also been utilized to propagate 

the scheme. Only one percent AWWs or up to five percent JSY beneficiaries heard 

about JSY from mass media including radio and TV or hoarding at PHC/SC. Majority 

heard about JSY from ANM, MO PHC/government doctor/health department, during 

training, other AWW or ICDS /CDPO office. 

However, key stakeholders such as PRIs, SHGs and others in the community have 

incomplete knowledge of roles and responsibilities of AWWs regarding JSY and its 

details. Moreover, there was no conscious effort for disseminating messages during 

Village Health and Nutrition Day, Immunization Sessions or RCH Camps. Hence, it is 

recommended to: 

1. Prepare a comprehensive BCC annual plan for ASHA intervention and JSY 

spelling out BCC objectives, key messages, target audience, use of different 

communication media, periodicity of undertaking it, at what levels and by 

whom. In doing so, the State may consider seeking professional inputs in 

59


formulating the communication strategy. Unless the community is aware of 

the roles of ASHAs and avails services from them, otherwise it could be 

difficult to sustain interest, if they are not able to make any regular and 

reasonable income. 

2. Timely payments to JSY beneficiaries are critical components for mobilizing 

women to seek institutional delivery services. The study found that payment 

to both JSY beneficiaries and AWWs was delayed, in several instances, despite 

clear instructions for immediate payment in the guidelines. Payments were 

done much later but made in one go. The guidelines suggest for payment to 

be made immediately at the place of delivery itself to JSY beneficiaries. The 

State should clearly spell out guidelines for making payments and it should 

be widely publicized and monitored in terms of entitlements. Making 

payments much later after delivery does not make sense. 

3. Study findings indicate that women have apprehensions about institutional 

deliveries for several reasons. The communication strategy should attempt to 

address fears about hospitals/health centres. Users of the scheme could 

explain women and help in reducing the fears. 

4. To ensure consistency in messages delivered through different information 

sources, the state should develop appropriate media briefing kits and 

orientation packages for different stakeholders in the form of Frequently 

Asked Questions (FAQs), preferably in local language. The information 

package should also detail out the role envisaged for different stakeholders. 

This package should be readily available and widely distributed. 

5. Interventions and pilot projects could be planned to ensure timely referral 

services including transport facilities. Transporters, Panchayat members, 

local leaders and even community members could be involved in planning 

and arranging transport apart from AWWs, ASHAs and ANMs. 

6. Since the dissemination activities undertaken so far has not given desired 

results and large proportion of the community was not aware of ASHA 

component or JSY, there is a need to conduct orientation programmes for the 

medical and health department, PRI members and other stakeholders for 

effective dissemination of both AWW and JSY activities. Civil society groups 

and networks of NGOs can be engaged to reach out to vast number of 

stakeholders. 

60

Appendix Tables

Appendix 1 

AWWS Tables 

Table 1.1: AWWs interviewed in Himachal Pradesh, 2007 

N % 

Total number of AWWs interviewed 150 100.0 

District name 

Shimla 

Una 

Chamba 

Block name 

Sunni 

Mashobara 

Amb 

Gagret 

Pukhari 

Tissa 

22 

25 

23 

35 

24 

21 

14.6 

17.2 

15.2 

23.2 

15.9 

13.9 

Table A1: Profile of AWWs in Himachal Pradesh, 2007 

Profile Percentage 

Total number of AWWs interviewed 150 

Age of AWW (in completed years) 

20 – 24 years 

25 – 29 years 

30 – 34 years 

35 – 39 years 

40 years or more 

Mean (in years) 

Years of schooling completed 

Below 8th std 

8th std 

Secondary (9–10 std) 

Higher secondary (11–12 std) 

Undergraduate and above 

Mean (years of schooling) 

Marital status of AWW 

10.3 

Unmarried 

9.4 

Married 

83.3 

Separated/divorced/widowed 

Religion 

7.3 

Hindu 100.0 

Caste/tribe of AWW 

Scheduled caste 

Scheduled tribe 

Other backward classes 

General/Others 

2.0 

12.7 

32.0 

29.3 

24.0 

35.5 

4.7 

7.3 

59.3 

22.0 

6.7 

24.7 

5.3 

5.3 

64.7

Appendix-1 

Table A2: Work history of AWWs in Himachal Pradesh, 2007 

Percentage 


Place of residence 

In this village/ town 

In another village close by 

In another town nearby 

Duration of Anganwadi work 

4 – 6 months 


10 months or more 

Mean (in months) 

Approximate monthly income from Anganwadi work (in rupees) 

501 – 1000 rupees 

1001 – 1250 rupees 

1250 – 1300 rupees or more 

Do not know/cannot say 

Mean (in rupees among those who received amount) 

Mode amount received by AWWs 

76.7 

21.3 

2.0 

1.3 

9.3 

89.3 

104.7 

0.7 

88.1 

10.7 

0.7 

1206.5 

1200.0 

Percent mentioned other source of income besides AWW payment/salary 30.0 (45) 

Table A3: Number of living children and place of previous delivery for AWWs in Himachal Pradesh, 2007 

Percentage 


AWWs with children 84.0 (126) 

Number of living children of AWW 

None 

One 

Two 

Three 

Four or more 

Mean 

Place where last child of Angawandi worker was delivered 

Government/ Municipal hospital 

Govt. ISM hospital/clinic 

Private hospital/ ISM clinic 

Home 

62 

16.0 

13.4 

44.0 

18.6 

8.0 

2.3 

31.7 

1.6 

3.2 

63.5

Appendix-1 

Table A4: Sources of information and selection of Anganwadi workers in Himachal Pradesh, 2007 

Percentage 


Percent AWWs heard about the ASHA 29.3 (44) 

Ways AWW FIRST came to know about ASHA 

ANM 

Health personnel 

Government doctor 

TV 

Radio 

Phamphlets/Hoardings at SC/PHC/CHC etc. 

CDPO/ICDS office 

Another Anganwadi worker 

Read about her in a book 

AWWs who thought that having ASHA as a co-worker at the village level would be useful to 

them 

Yes, ASHAs would be useful to AWW 

No, not useful 

Cannot say 

Reasons for believing that ASHAs would be useful/not useful to AWWs * 

ASHAs will help AWWs in health related work/benefit to villagers for immunization etc. 

ASHAs can provide information to AWWs about the community and people’s health needs 

Help / benefit people / cash benefit / It is good for people 

ASHAs will create awareness among women / give information about hospital 

ASHA worker could solve problems of pregnant women 

Can yield better results, if ASHA and AWW work with cooperation 

No benefit, I can worked independently 

Do not know / No knowledge of ASHA worker’s 

No response 

Percent mentioned that Gram Sabha approved their name 69.3 

* Multiple responses 

63 

40.9 

13.6 

11.4 

6.8 

6.8 

6.8 

6.8 

4.5 

2.3 

78.7 

1.3 

20.0 

59.3 

17.3 

4.7 

1.3 

0.7 

0.7 

0.7 

7.3 

14.0

Appendix-1 

Table A5: Topics covered and arrangements made in the training of AWWs in Himachal Pradesh, 2007 

Percentage 

AWWs attended any training programme in the last one year 71.3 (107) 

Topics covered during training program* 

Infant and child care (immunization) 

Nutrition 

HIV and AIDS 

Women and health (FP, ANC, breastfeeding)/registration 

Anganwadi centres 

Adolescent education 

Pre school education/games for children 

National Rural Health Mission (NRHM) 

Disposal of waste water/clean drainage 

Organising a group meeting 

Water supply at home /safe drinking water 

Reproductive and sexual health 

Curative care 

Management of diarrhoea and pneumonia 

Others 

Mean duration of time when training was held for AWWs (months ago) 8.0 

Mean number of training days attended by Angawadi worker (in days) 

Range 

Place where the training was held 

AWW centre, balbhavan 

Nursing training centre 

PHC / CHC 

Panchayat 

School 

Others 

43.9 

33.6 

25.2 

23.4 

18.7 

14.0 

14.0 

9.3 

8.4 

6.5 

2.8 

1.9 

1.9 

0.9 

3.7 

5.1 

1 – 15 

AWWs that voiced the need for additional arrangements at the training centre 29.9 (32) 

Additional arrangements needed at training centre* 

Beds / bed sheets should be provided 

Latrine / bathroom facilitites 

Water problem should be tackled 

Lack of space/training room should be bigger 

Electricity / fan is required 

Better if there was a TV facility 

Food arrangements should be proper 

Charts / practical demonstrations should be there 

Others 


58.9 

26.2 

4.7 

3.7 

3.7 

2.8 

37.5 

31.3 

21.9 

15.6 

15.6 

15.6 

12.5 

12.5 

12.5 

Table A6: AWWs views on logistic arrangements at the place of training in Himachal Pradesh, 2007 

Percentage 

Good Average Poor 

AWWs views on logistic arrangements 

Sitting arrangement 

Size of the room 

Accommodation facilities 

Arrangement for food 

64 

82.2 

72.0 

70.1 

72.9 

13.1 

24.3 

22.4 

21.5 

3.7 

2.8 

6.5 

4.7

Appendix-1 

Table A7: Views about the training among AWWs in Himachal Pradesh, 2007 

Percentages 

Number of AWWs that attended training within the last year 107 

Perception about the trainers 

Trainers were very good 

Trainers were good 

Trainers were not at all good 

AWWs mentioning that the training was participatory in nature 

Trainers encouraged to ask questions 

Trainers answered questions properly 

Training was not participatory 

AWWs who said that the trainer used charts/models to explain the topics 83.2 (89) 

Training aids* 

Posters 

Lectures 

Book 

Flip charts 

TV/video/CD 

Pamphlets 

Role plays 

Folk songs 

Models/blackboards 

Others 

Quality of training material 

Very good 

Good 

OK 

Usefulness of the training 

Useful 

Somewhat useful 


Table A8: Payments received during training by Anganwadi workers in Himachal Pradesh 

Percentage 

Number of AWWs who attended training within the last year 107 

Amount received during training 

Received amount due (Rs. 100 x number of days attended training as DA + Rs. 100 

transportation) 

Received amount less than due 

Received amount more than due 

Do not know 

Mean (Rupees among those who have received ) 

Table A9: Scoring of knowledge of AWWs in Himachal Pradesh, 2007 

44.9 

54.2 

0.9 

77.6 

25.2 

1.9 

79.8 

53.9 

47.2 

44.9 

16.9 

15.7 

15.7 

5.6 

2.2 

1.1 

31.5 

67.4 

1.1 

93.5 

6.5 

0.0 

85.2 

1.2 

13.6 

216.0 

Number Percentage 

Total number of AWWs interviewed 150 100.0 

Grade O (10 out of 10) 

Grade A (8 – 9 out of 10) 

Grade B (6 – 7 out of 10) 

Grade C (3 – 5 out of 10) 

65 

2 

74 

64 

10 

1.3 

49.3 

42.7 

6.7

Appendix-1 

Table A10: Knowledge of AWWs about ANC care in Himachal Pradesh, 2007 

Total number of AWWs interviewed 

AWWs that know that 

Percentage 

150 

During diarrhoea a child should be given increased quantity of fluids 100.0 

The mother should continue breastfeeding her child during diarrhoea 98.7 

A pregnant woman should take two TT injections 96.7 

The minimum birth weight of the newborn child should be 2500 grams 96.0 

Recommended to exclusively breastfeed child for 6 months 84.0 

A woman should undergo a minimum of three antenatal checkups during pregnancy 82.0 

A woman should consume a minimum of 100 IFA tablets during pregnancy 72.1 

All five cleans that need to be maintained during delivery 


57.3 

Table A11: Knowledge about complications during pregnancy among AWWs in Himachal Pradesh, 2007 

Percentage 


Knowledge about type of complications women can experience during pregnancy* 

Swelling of hands and feet 

Vomiting 

Paleness/Anemia 

Excessive bleeding 

Abdominal pain 

Body pain/backache 

Feeling uneasy 

High fever 

Weak or no movement of foetus 

Visual disturbance 

Abnormal position of foetus 

Convulsion 

Weight loss 

Others 

Do not know 

Actions AWW feels are to be taken upon recognition of any signs of complications in a 

pregnant woman* 

Immediately refer her to the nearest functional FRU (Upgraded CHC, Sub division/district 

hospital) 

Refer her to a government accredited hospital 

Take her to the nearest functional FRU 

Ask her to consult the ANM the next day 

Refer her to a private accredited hospital 

Provide money for transportation 

Others 


66 

67.3 

58.7 

46.0 

34.0 

24.7 

23.3 

18.7 

15.3 

10.0 

6.7 

6.7 

4.0 

0.7 

2.7 

4.7 

54.0 

33.3 

18.0 

16.7 

0.7 

0.7 

3.3

Appendix-1 

Table A12: Knowledge about common complications during pregnancy / delivery that can result into death 

of a woman, Himachal Pradesh, 2007 

Percentage 


Common complications during pregnancy /delivery that can result into death of a woman* 

Weakness of the mother 

Excessive bleeding 

Blood pressure problem 

Abnormal position of the foetus 

Abdominal pain 

Foetus dies in mother’s womb 

Fever 

Headache 

Convulsions / fit 

Tetanus 

Others 

Do not know 


74.0 

59.3 

42.7 

17.3 

16.0 

12.0 

10.0 

2.7 

2.0 

1.3 

11.3 

4.0 

Table A13: Knowledge about immunization and child care among AWWs in Himachal Pradesh, 2007 

Percentage 


Vaccines named that are to be given to children as part of the Universal Immunization 

Programme* 

BCG (TB) 

DPT 

Measles 

Booster dose 

OPV 

TT 

AWWs knowledge of period when newborns are most likely to die 

Soon after birth/within 24 hours 

Within 1 week of birth 

Between 1 to 2 weeks of birth 

Between 3 – 4 weeks of birth 

Within 6 weeks 

Within 2 years 

Other 

Do not know 

No response 


67 

99.3 

98.0 

95.3 

78.7 

42.0 

31.3 

35.3 

24.7 

6.7 

10.0 

1.3 

7.3 

0.7 

15.3 

0.7

Appendix-1 

Table A14: Responsibilities, recognition and feelings about being an AWW in Himachal Pradesh 

Percentage 


Responsibilities as an Anganwadi worker* 

Help in immunization program/weight 

Create awareness on health 

Registration of birth and death 

Motivating and mobilizing community 

Create awareness on basic sanitation & hygiene/clean the environment around 

Village health planning 

Provide basic curative care/ Child related problems/child care 

Promote good health practices 


Provide ANC care 

Pre education for small children/education/To educate 3 to 6 years children 

Provide nutrition/motivate pregnant women for nutrition/nutrition help/provide nutrition to children 

Accompanying delivery cases 

Counseling 

Work with ANM/dai 

Make timely referrals 

Adolescent education 

Record registration / maintainance of records (nutrition, SHG) 

Other 

Ways one can recognize Anganwadi worker in the village* 

Because of my work 

In the role of Anganwadi / Sahyogini 

I informed the villagers 

As a well-wisher / good worker 

I attend meetings at the health centre 

People know that I can get them money 

Gram sabha / surpanch introduced me to the village 

As one working with ANM 

Others 

Do not know 

Ways respondent feels about being an Angawandi worker* 

Feels good 

I get the opportunity to serve the community 

I like that I get information which I can pass on to the community 

Better if I received more money 

I get to know more about health 

I have too many responsibilities 

Reasons for feeling good about being an AWW* 

I feel good that poor people motivated by us will get benefits as JSY beneficiaries 

Increases knowledge and understanding 

It is necessary to create awareness among illiterate/ignorant people 

I know about antenatal and natal care 

Villagers respect/ support me /acknowledge my work 

So that people in the village recognize me 

I get money 

Like to serve the community, but it is a lot of work 

I know all the families in the village 

It is very good to do work with children/interested in children/like to talk to people and to accompany 

with child/good work for child/I like to talk to people and children 

Reduces misconception 

Because of targets my cases are claimed by ANM 

I get to know the doctor 

To identify myself 

Others 

Do not know 

Ways the community feels about the Anganwadi worker (from the AWWs perspective)* 

Appreciate the work 

No interaction 

Consider me for health problems 

Does not accept me 

Cannot say/Do not know 


68 

82.0 

58.7 

44.7 

38.7 

31.3 

25.3 

23.3 

19.3 

16.7 

15.3 

14.7 

12.0 

8.0 

8.0 

6.7 

6.0 

4.0 

2.0 

3.3 

57.3 

42.0 

30.0 

30.0 

16.0 

12.7 

7.3 

4.7 

0.7 

1.3 

99.3 

16.7 

7.3 

2.7 

3.3 

2.0 

60.7 

30.0 

24.7 

22.0 

20.7 

16.7 

11.3 

11.3 

10.7 

8.0 

4.7 

2.7 

2.0 

0.7 

1.3 

2.7 

96.7 

12.7 

9.3 

2.0 

2.0

Appendix-1 

Table A15: Functioning of AWWs in Himachal Pradesh, 2007 

Percentage 


Ways AWWs carry out their work* 

Go house to house/VLCC/Register work/create awareness at home 

Attend immunization sessions 

Organize health days at AWW/ Camps/visits in a camp/attend camps 

Accompany ANM 

Accompany for delivery 

Provide nutritional support to children 

Others 


Table A16: Knowledge about care for pregnant women, Himachal Pradesh, 2007 

Percentage 


Advice given to a pregnant woman by respondent* 

Diet 

Immunization 

ANC care (check up, IFA tablets, TT)/registration/health care 

Institutional delivery 

Delivery care 

Breastfeeding 

Personal hygiene/cleanliness 

Danger signs 

Newborn care 


Breast care 

Others 

Services provided to a pregnant woman by respondent* 

Provide nutritious food 

Ensure IFA consumption 

Advise for antenatal check-up 

Accompany for TT/immunization 

Accompany for antenatal check-up 

Identify risk factor in antenatal mothers 

Attend outreach day 

Others 

Advice given to a woman during postnatal period* 

Breastfeeding/give information about colostrum 

Nutrition 

Immunization 

Newborn care 

Follow-up advice 

Childhood morbidity management 

Hygiene 


Other 

Actions suggested to be done to further enhance service in the community 

Increase awareness among people about JSY/promote JSY 

More facilities required 

Advertisement 

Should not argue 

No child before 3 years/family planning 

Increase AWW pay 

Talk to lady doctor 

Need lady doctor / Need a lady gynaecologist 

More awareness about health 

Other / irrelevant answers 

Do not know 

No response 


69 

92.0 

65.3 

20.0 

16.7 

6.0 

2.0 

8.0 

94.7 

76.7 

66.0 

51.3 

24.7 

22.0 

17.3 

14.7 

14.7 

12.7 

8.7 

2.7 

93.3 

64.0 

51.3 

22.7 

20.0 

2.0 

2.0 

2.0 

77.3 

76.0 

68.0 

62.0 

26.7 

9.3 

3.3 

2.0 

1.4 

14.7 

4.0 

3.3 

2.7 

2.7 

2.0 

1.3 

0.7 

0.7 

45.4 

22.7 

3.3

Appendix-1 

Table A17: Availability and utilization of drug kits by AWWs in Himachal Pradesh, 2007 

Percentage 


Percent received the drug kit 99.3 (149) 

Time when received the drug kit 

Immediately after tarining 

Some days after training 

Many (months) after training 

1 Year before/before year/more than 1 year 

Other 

No response 

Materials supplied in the drug kit* 

Paracetamol tablets I. P. 

Bandage, cotton, thread 

IFA 

ORS 

Tincher 

Ear drop/eye drop 

Needle, blade, scissor 

Momadzole/monodryl/momoandajol 

Paediatric drugs 

Cough syrup 

Soap 

Dicyclomine Hydrochloride tablets 

Chloroquine Phosphate tablets 

Albendazole/amandlye/amandliole 

Mala D 

Nirodh / condom 

Mamta/delivery kit 

Others 

Percent ever used the medicines available in the kit 97.3 (145) 

Average number of days ago when the last time drug kit was used 

Range 

Things dispensed the last time AWW used the drug kit* 

Paracetamol tablets I. P. 

IFA 

ORS 

Tincher 

Eye drop 

Dicyclomine Hydrochloride tablets 

Paediatric drugs 

Cough syrup 

Chloroquine Phosphate tablets 

Nirodh / condom 

Mamta / delivery kit 

Other 

Ways medicines are being replenished* 

CDPO office/ICDS/Project officer/ICDS office 

Get supplies from otheranganwadi worker 

Get supplies from ANM 

Get supplies from CHC/PHC 


70 

8.7 

18.8 

34.9 

20.8 

9.4 

7.4 

99.3 

87.9 

68.5 

55.0 

38.9 

38.9 

30.2 

24.2 

21.5 

14.1 

10.1 

9.4 

8.1 

5.4 

4.0 

3.4 

0.7 

10.1 

73.3 

1 - 999 

89.7 

20.7 

20.0 

6.9 

6.2 

4.1 

4.1 

3.4 

1.4 

0.7 

0.7 

6.9 

43.4 

36.6 

17.2 

11.7

Appendix-1 

Table A18: Awareness about JSY and its benefits among AWWs in Himachal Pradesh, 2007 

Percentage 


AWWs who had heard about JSY 84.0 (126) 

Source from whom FIRST heard about JSY 

ANM 

MO PHC/government doctor/health department 

During training 

AWW 

ICDS /CDPO office 

Supervisor/MHW 

Village panchayat leader 

Women in the community 

TV/paper/radio 

Others 

Understanding the purpose of JSY* 

For poor family 

Promotion of institution delivery 

Intake of nutritious food 

Benefit of mother 

Immunizing children 

Registration of birth/death 

Financial help/poor people get financial benefit 


For rich and influential family 

Population stabilization 

Other 

Do not know 

Persons eligible for JSY* 

Women from BPL families 

Women from SC/ST families 

All women during pregnancy 

Women with less than 2 children 

IRDP 

Women above 19 years of age 

Others 

Ways followed to identify possible beneficiaries* 

Through home visits 

If a woman feels uneasy or is vomiting, I take her to the hospital 

By contacting people 

When women come for check-ups/immunization 

Through IRDP number which is taken from panchayat/BPL card/IRDP record from PRI/Took 

registration of BPL With the help of PRI/panchayat recognises 

ANM tell me about which woman is pregnant 

Others 


71 

61.1 

21.4 

15.1 

10.3 

7.9 

4.0 

0.8 

0.8 

0.8 

3.2 

68.3 

64.3 

47.6 

40.5 

26.2 

19.0 

7.9 

7.1 

3.2 

1.6 

2.4 

2.4 

97.6 

12.7 

7.1 

7.1 

5.6 

1.6 

0.8 

78.6 

35.7 

33.3 

27.0 

15.9 

4.8 

4.0 

0.8

Appendix-1 

Table A19: Cash assistance available under different schemes for AWW and JSY beneficiaries in Himachal 

Pradesh, 2007 

Percentage 

Number of AWWs who have heard of JSY 126 

Cash assistance available under different schemes for an Anganwadi worker* 

I do not get anything 

Get money for accompanying women for delivery 

Get money for delivery 

Get money for transport 

Get money for immunization 

Other (ANMs take away Rs. 25) 

Do not know 

Assistance available to beneficiary mothers* 

Get money (Rs. 500) for home delivery 

Get money (Rs. 700 – Rs 1400) for institutional delivery 

Gets nutritional supplement from Anganwadi 

No expense for transportation to hospital 

Free medicines 

Free treatment/delivery/immunization 

Protection of mother and child health 

Receive good quality services 

Receive Rs. 400 for sterilization 

Get services during antenatal period 

Other 

Do not know 


Table A20: AWW’s role in promoting JSY in Himachal Pradesh, 2007 

Percentage 


Percent AWW playing a role in promoting JSY 93.7 (118) 

Ways followed to promote JSY* 

Talk to women when they approach us and register their name 

Door to door visit 

Publicity during immunization/health days/talk in VLCC (SHG)/Meetings/through camps 

Talk to other family members 

Talk to husband 

Distribute pamphlets/brochures 

Others 

Importance of the work under JSY as compared to other tasks AWW has to fulfil 

Very important 

Important 

Not so important 

Not at all important 

Total number of AWW interviewed 150 

Suggested ways to further promote (propagate) JSY * 

Door to door visit 

Advertisement 

More financial benefits 

Village meeting 

Satisfied clients 

Others 

Do not know 


72 

57.9 

17.5 

5.6 

2.4 

1.6 

0.8 

18.3 

66.7 

50.0 

11.9 

5.6 

4.8 

4.8 

4.0 

1.6 

0.8 

0.8 

0.8 

2.4 

85.6 

55.9 

47.5 

27.1 

1.7 

0.8 

5.1 

45.2 

53.2 

0.8 

0.8 

71.0 

58.1 

38.7 

38.7 

9.7 

6.5 

3.2

Appendix-1 

Table A21: Role of AWWs in accompanying JSY cases and arranging for institutional delivery in Himachal 

Pradesh, 2007 

Percentage 


Number of JSY cases AWW has accompanied for institutional delivery so far 

None 

1 

2 

3-5 

6 or more 

Do not know 

Mean (number of cases among those who have accompanied someone N = 53) 

2.8 

Number of AWWs interviewed 

Place where AWWs usually take women for delivery * 

150 

Government hospital 

69.3 

CHC 

10.7 

PHC 

22.0 

Private hospital/clinic 

0.7 

Other (home/TBA) 

0.7 

No case till now 

Transport facility usually suggested to transfer a case from the village to the health facility* 

8.7 

Private vehicle/client’s own vehicle 

79.3 

I do not arrange for trasnport 

10.0 

Public transportation 

7.3 

Other (walking only) 

1.3 

No case till now 

Arrangements made for transport* 

4.0 

Call transporters over phone 

66.9 

If transport facility is available, I call from the village 

24.3 

Beneficiaries themselves arrange the transport 

10.3 

Tell them (transporters) in advance/give money in advance 

8.8 

Arrange transport as soon as possible/local arrangements 

5.1 

Arrange private shuttle/vehicle standing near the bus stand 

2.2 

I keep in contact with transporters 

2.2 

Other 

2.8 

Do not know / Till now I have not arranged any transport 

Availability of transport facility 

2.2 

Always available 

83.8 

Not available always 

16.2 

Average time taken to arrange for transport (in minutes) 

34.0 

Range (in minutes) 

5 - 180 

Do not know/cannot say (% of AWWs interviewed) 

4.4 

Average distance of the facility where the JSY beneficiary is usually referred to (in kms) 

12.0 

Range (in kms) 

0 - 60 

Do not know (% of AWWs interviewed) 

2.7 

Average time it takes to reach the institution (in minutes) 

43.3 

Range (in minutes) 

5 - 240 



1.3 

Table A22: Average time taken to reach the institution by distance of the facility from residence of JSY 

beneficiary, Himachal Pradesh, 2007 

Mean distance of the facility where JSY beneficiary is 

usually referred to (km) 

1 

Km 

2 

Km 

3-5 

Km 

6-10 

Km 

11-15 

Km 

16+ 

Km 

57.1 

10.3 

13.5 

15.9 

2.4 

0.8 

Do not Total 

know 

Number of AWWs mentioning the distance of 

facility where the JSY beneficiaries are usually 

referred 

15 12 29 33 13 44 4 150 

Mean time taken to reach the institution (min) 12.0 26.3 21.0 28.2 40.4 84.4 65.0 43.3 

73

Appendix-1 

Table A23: Cooperation and cash assistance received at the place of delivery as perceived by AWW in 

Himachal Pradesh, 2007 

Percentage 

Number of AWWs interviewed 150 

Cooperation with health personnel at the institution 

Cooperation is very good 

Cooperation is good 

Neither good nor bad 

Cooperation is bad 

No cooperation 

Do not know 

Percent mentioning that the beneficiary women are given any cash assistance 62.7 (94) 

Amount AWW states as being disbursed to the beneficiary (in rupees) 

25 

200 

300 

500 

700 

1000 

1200 

1600 

Do not know 

No response 

Mean (among those who mentioned that the beneficiary women are given cash assistance for 

home or institutional delivery, n=87) 

Range (in Rs) 

Person who makes the payments to the beneficiary* 

ANM/male health worker 

Accountant / clerk / babu 

Doctor at the institute 

MO CHC/PHC 

Do not know 

Time when the cash assistance is given to the beneficiary 

At the time of registration 

At the time of antenatal check-ups 

Much before the delivery 

Within a week before the expected date of delivery 

Immediately after the delivery 

Within a week after the delivery 

Much later 

Not received yet 

Other 

Do not know 

Mode of payment for cash assistance 

Entire cash in given in one go 

Cash assistance is given in instalments 

I do not know 

Place where beneficiaries get the payment* 

At the PHC 

At the SC 

At the institution (place of delivery) 

At the CHC 

At home/within the village 

Others 

Do not know 

No response 

26.0 

59.3 

8.7 

2.0 

0.7 

3.3 

1.1 

2.1 

1.1 

37.9 

7.4 

5.3 

35.8 

1.1 

3.2 

5.3 

816.4 

25 – 1600 

AWWs mentioning that there are delays in beneficiaries receiving the money 12.6 (12) 

Reasons for the delay in receiving the money* 

Lack of budget at the centre 

Doctor’s signature is missing 

There are long queues to collect cash assistance 

Others 


74 

56.8 

21.1 

16.8 

7.4 

9.5 

18.9 

5.3 

12.6 

3.2 

32.6 

22.1 

7.4 

1.1 

2.1 

8.4 

70.5 

25.3 

4.2 

34.7 

28.4 

27.4 

11.6 

11.6 

1.1 

5.3 

1.1 

75.0 

25.0 

25.0 

33.3

Appendix-1 

Table A24: Handling of women visiting natal place (other village) for delivery in Himachal Pradesh, 2007 

Percentage 


Ways followed to handle a case where a woman goes to her maternal home for delivery/to a 

different village where the respondent is not responsible* 

Ask her to take proper care/go for institutional delivery 

Woman gets benefit at her natal place and not from us 

I make sure she gets the benefit 

Women receive the money at the place of delivery/at her natal place, so there is no problem 

Give JSY card from the village and referral slip 

Take care of immunization of child 

I will still accompany her to the place of delivery and take total care 

If nearby, I ask to call at the time of delivery 

Try to convince her to deliver in this village (for money reasons) 

AWW / health functionairy at woman’s natal place takes care 

Other 

Do not know, have not had such case till now 


40.0 

38.7 

12.0 

10.7 

7.3 

6.0 

5.3 

3.3 

2.0 

0.7 

4.7 

24.0 

Table A25: Reasons for preferring home delivery despite cash assistance for institutional delivery in 

Himachal Pradesh, 2007 

Percentage 


Perceived reasons for women to deliver at home despite cash assistance paid under JSY for 

institutional delivery* 

Women believe they get better care at home 

Fear of going to hospital/needle/injection/equipments 

Fear of doctor/nurse 

There are expenses in the hospital/Home delivery is cheaper 

Shy of going to a doctor for delivery 

Illiteracy and lack of understanding of the importance of institutional delivery 

Women do not believe us (AWWs) 

Unavailability of transport facility on time 

If there are any complications they go to hospital or contact us 

Staff is not cooperative/rude 

The Clinic is far away 

Other 

Do not know 


75 

50.7 

43.3 

43.3 

43.3 

26.0 

16.7 

7.3 

4.7 

1.3 

1.3 

0.7 

28.7 

4.0

Appendix-1 

Table A26: Brief details of AWW’s interaction with her last client in Himachal Pradesh, 2007 

Percentage 


Number of AWWs who had handled a case 65.3 (98) 

Time when the last client availed services from AWW (days before) 

Mean days ago when the last client availed services from AWW (among those who had 

handled a case) 

No case served by AWW (%) 

Average age of the last client (in years) 25.4 

Caste of the client 

Schedule caste 

Schedule tribe 

OBC 

General 

Do not know 

Reasons for the interaction* 

Immunization 

Registration of pregnancy 

For BPL card 

Collect medicines for fever/ back pain / vomiting 

Nutrition 

Delivery/to get advice about place of delivery 

Information regarding sterilization 

Antenatal care/check-up 

Home visit/health advise 

IFA tablet distribution 

I had no contact with anyone 

Post natal care 

Procuring Mala D or condom 

Pain in lower abdomen 

Did not get money after delivery, hence came to me 

Others 

Do not know 


Table A27: Details of AWWs when last accompanied women for delivery in Himachal Pradesh, 2007 

Percentage 

and means 


Mean duration of days ago when AWW last accompanied a woman for delivery (in days among 

108.6 

those AWWs who accompanied) (n=17) 

AWWs who stayed with JSY beneficiary at the place of delivery 6.0 (9) 

Number of hours AWW stayed with JSY beneficiary at the place of delivery 

One hour 

Two hours 

Half a day 

One day 

Two days 

Average number of hours (among those who stayed with JSY beneficiary at the place of 

delivery) 

76 

78.6 

34.7 

48.0 

4.1 

6.1 

37.8 

4.1 

40.8 

30.6 

21.4 

16.3 

13.3 

12.2 

11.2 

7.1 

7.1 

6.1 

5.1 

3.1 

1.0 

1.0 

1.0 

5.1 

1.0 

33.3 

11.1 

22.2 

22.2 

11.1 

13.9

Appendix-1 

Table A28: Networking of Anganwadi worker with other stakeholders in Himachal Pradesh, 2007 (percentage) 

Stakeholders ANM Block PHC NGO SHG PRI Health and Village 

facilitator staff staff 

sanitation 

committee 

mandal 

AWWs who met the following 100.0 29.3 70.7 4.7 82.0 87.3 20.0 50.0 

Frequency of meeting the 

stakeholders 

(150) (44) (106) (7) (123) (131) (30) (75) 

Once a week 

33.3 9.1 10.4 14.3 16.3 16.8 16.7 4.0 

Fortnightly 

23.3 9.1 17.0 0.0 15.4 23.7 10.0 17.3 

Once a month 

42.0 27.3 43.4 14.3 65.0 40.5 46.7 58.7 

Less frequently 

Time when last met the stakeholders 

1.3 54.5 29.2 71.4 3.3 19.1 26.7 20.0 

1 – 2 days ago 

16.0 4.5 4.7 16.7 12.2 9.9 3.3 4.0 


34.0 13.6 10.4 16.7 13.8 22.1 20.0 4.0 


22.0 9.1 16.0 16.7 22.8 20.6 20.0 21.3 


24.0 22.7 31.1 16.7 37.4 26.0 13.3 34.7 


0.7 27.3 11.3 16.7 6.5 7.6 13.3 6.7 


3.3 22.7 26.5 16.7 7.3 13.7 30.0 29.3 

Mean number of days ago when met 

last 

Activities done by AWW in 

collaboration with the stakeholders* 

Organizing health days/camp 

Motivate pregnant women for check 

ups 

Assemble children for nutritional 

supplements 

Enhance utilization of immunization 

services 

Guidance to overcome problems 

Ensure payment of assistance to benef. 

Take care of antenatal mothers 

Help in administration/registration 

work/ IRDP/BPL 

Advice/provide family planning 

services 

Provide health awareness to 

community/ on AIDS/Adolescent 

education 

Provide curative care 

Motivate for saving/give loan 

Promote sanitation and hygiene 

Get medicine supply 

Nothing 

School education/anganwadi help/ 

anganwadi meeting 

Others 

Do know know 

No response 

AWWs experience in terms of support 

from stakeholders 

Yes, they support 

They somewhat support 

No support/cannot say 

No response 


11.3 

26.0 

21.3 

11.3 

74.0 

14.0 

10.0 

6.7 

0.7 

3.3 

14.0 

5.3 

0.0 

2.0 

0.7 

0.0 

0.7 

0.7 

0.0 

0.0 

99.3 

0.0 

0.7 

0.0 

49.4 

27.3 

4.5 

2.3 

15.9 

13.6 

0.0 

0.0 

11.4 

2.3 

34.1 

11.4 

2.3 

4.5 

6.8 

0.0 

0.0 

6.8 

0.0 

4.5 

95.5 

2.3 

0.0 

2.3 

77 

25.2 

20.8 

17.0 

11.3 

31.1 

8.5 

7.5 

11.3 

11.3 

6.6 

32.1 

10.4 

0.0 

2.8 

0.0 

0.0 

0.0 

2.8 

1.9 

2.8 

99.1 

0.0 

0.9 

0.0 

39.0 

28.6 

0.0 

14.3 

14.3 

28.6 

0.0 

0.0 

14.3 

0.0 

14.3 

0.0 

14.3 

14.3 

0.0 

0.0 

0.0 

0.0 

0.0 

0.0 

100.0 

0.0 

0.0 

0.0 

17.3 

4.1 

3.3 

4.9 

4.9 

23.6 

0.0 

1.6 

2.4 

3.3 

12.2 

4.1 

78.9 

4.9 

0.0 

0.0 

1.6 

0.8 

0.0 

0.8 

98.4 

0.0 

0.0 

1.6 

17.0 

7.6 

4.6 

10.7 

2.3 

55.0 

3.1 

0.0 

24.4 

3.8 

16.0 

4.6 

6.1 

17.6 

0.0 

0.0 

2.3 

3.8 

0.0 

2.3 

96.2 

0.8 

0.0 

3.1 

20.4 

16.7 

10.0 

3.3 

23.3 

6.7 

0.0 

6.7 

3.3 

6.7 

16.7 

16.7 

3.3 

50.0 

0.0 

0.0 

0.0 

6.7 

0.0 

0.0 

96.7 

0.0 

0.0 

3.3 

22.1 

10.7 

9.3 

5.3 

6.7 

34.7 

6.7 

1.3 

6.7 

5.3 

22.7 

10.7 

17.3 

13.3 

0.0 

1.3 

1.3 

2.7 

0.0 

0.0 

97.3 

1.3 

0.0 

1.3

Appendix-1 

Table A29: The roles of other stakeholders in the implementation of AWW in Himachal Pradesh, 2007 

(Percentages) 

Support from/roles of other 

stakeholders* 

Arrange for money/help from 

economic point of view 

Selection of AWW 

Training of Anganwadi 

Advise Anganwadi 

Treat women 

Create awareness of JSY among 

community 

Serve the village by building 

roads/drainage lines/ water facilities 

Maintain hygiene/sanitation 

Motivate people for institutional 

delivery 

Birth and death registration 

Immunization of children 

Provide medicines/drug kits 

Organize health camp/village health 

day/organised meeting 

Motivate me from time to time/good 

cooperation 

Provide supplies 

Collect grading card/give BPL 

certificate/check BPL family 

Check registers/records/performance 

of AWWs 

Runs saving scheme/provide loans 

Ensures widow pension 

Solve problem 

No one visits 

Not available 

Do not know 

No response 


Block 

officials 

12.0 

0.0 

4.7 

1.3 

0.7 

5.3 

1.3 

0.7 

0.0 

1.3 

2.0 

1.3 

3.3 

0.7 

0.0 

0.0 

0.7 

0.0 

0.0 

2.7 

17.3 

0.7 

54.0 

5.3 

Panchayati 

Raj 

Institutions 

78 

8.0 

0.7 

2.0 

4.0 

0.0 

14.0 

25.3 

14.7 

1.3 

12.7 

0.7 

0.0 

9.3 

2.0 

0.7 

12.0 

4.0 

0.7 

2.7 

8.0 

4.0 

0.7 

22.0 

2.0 

Non 

Government 

Organizations 

0.0 

0.0 

0.7 

0.0 

0.0 

1.3 

0.0 

0.0 

0.0 

0.0 

0.0 

0.0 

0.0 

0.7 

0.0 

0.0 

0.0 

0.0 

0.0 

2.0 

16.7 

2.0 

64.7 

14.0 

Self 

help 

group 

6.7 

0.0 

1.3 

4.7 

0.7 

22.0 

2.0 

0.7 

6.0 

0.0 

4.0 

2.0 

4.7 

4.0 

0.0 

2.0 

0.0 

10.7 

14.7 

20.0 

14.0 

1.3 

20.0 

4.0 

Community 

Based 

Organization 

2.0 

0.0 

0.0 

0.0 

0.7 

6.0 

2.0 

0.7 

2.0 

0.0 

3.3 

0.7 

0.7 

2.0 

0.0 

0.0 

0.0 

0.0 

0.0 

4.0 

16.7 

1.3 

58.7 

9.3 

Health 

department 

26.7 

0.0 

4.7 

4.0 

3.3 

20.0 

1.3 

3.3 

18.7 

6.7 

28.0 

30.7 

20.7 

6.7 

6.7 

0.0 

5.3 

0.0 

0.7 

2.0 

2.7 

0.0 

16.7 

4.7

Appendix-1 

Table A30: Process of receiving cash incentive money as AWW, Himachal Pradesh, 2007 

Percentage 


AWWs who have received any cash incentive till now 18.0 (27) 

Services for which Anganwadi worker received cash incentive money* 

Attending JSY beneficiary 

Immunization of children 

Family planning cases 

Do not get any money 

Person who usually disburses the cash incentive* 

ANM/FHW 

MO CHC/PHC 

Other (CDPO Office) 

Do not know 

11.1 

81.5 

3.7 

11.1 

AWWs who received money for their last beneficiary case 10.0 (15) 

Average amount received for last beneficiary case (in rupees among those who received money 

N=15) 

312.5 

Place where AWW got the payment for her last case 

At the CHC 

At the PHC 

At the sub-centre 

Anganwadi Centre 

Other 

Time when AWW got the payment for her last case 

Same day/immediately after delivery 

Within a month 

More than a month after delivery 

Do not know 

AWWs who did not get the cash incentive on time 20.8 (5) 

Reasons for the delay in payment of cash incentive* 

Lack of budget at the centre 

JSY has just started hence there is some delay 

Have to fill up form which has to go for approval before making the payment 

Do not know 


Table A31: Average amount received from government (other than training) by AWW in the last three months 

Months of payments 

A. Attending JSY beneficiary 

Mean amount received 

Range 

Number received money 

B. Immunization of children 

Mean amount received 

Range 


C. Other services 

Amount received 


October ‘06 

(Amount in Rs) 

25.0 

25 

2 

33.7 

25 – 200 

61 

79 

25.0 

1 

November‘06 


25.0 

25 

1 

32.0 

25 – 100 

58 

25.0 

1 

70.8 

8.3 

4.2 

8.3 

4.2 

8.3 

70.8 

4.2 

4.2 

20.8 

33.3 

41.7 

4.2 

40.0 

20.0 

20.0 

20.0 

December ‘06 


25.0 

25 

1 

36.9 

25 – 100 

62 

25.0 

1

Appendix-1 

Table A32: Reported satisfaction with the cash incentive in Himachal Pradesh, 2007 

Percentage 

AWWs that received any cash incentive money till now 60.7 (91) 

Percent satisfied with the cash incentive received under JSY 

Satisfied 

Somewhat satisfied 

Indifferent 

Unsatisfied 

Do not know 

Reasons for satisfaction/dissatisfaction with the cash incentives* 

Able to serve the community / visit far off villages to offer public service 

Working within the village so it is ok 

We get money 

I get to learn many things 

Too much work and too little money 

Did not get JSY money from ANM/other officials 

Delay in getting payment 

Money should be available timely 

Get money only if activities are done 

Some health workers are not working but favoured and paid 

Do not know 


80 

15.4 

17.6 

2.2 

62.6 

2.2 

11.0 

9.9 

7.7 

6.6 

52.7 

20.9 

13.2 

9.9 

5.5 

1.1 

6.6

Appendix-1 

Table A33: Supervision and monitoring of AWWs in Himachal Pradesh, 2007 

Percentage 

Number of AWWs interviewed 150 

AWWs maintaining any records or registers 96.0 (144) 

Types of records maintained as an AWW* 

Immunization 

Child registration, nutrition/ growth-chart register, food ration record 

Drug register/medicine kit 

Birth and death registration 

ANC register (name, address, DoD, registration, weight) 

Household survey with history of marriage register and BPL family record 

Delivery case record 

Adolescent girls register 


Stock register 

Attendance register/teaching/pre school education register 

SHG register/BLCC/BLCC compute/VLCC/former group registered 

Sanitation (spraying of bleaching powder) 

Other 

Mean number of hours per week taken to maintain/update the records by AWW 

Range in hours (Minimum - Maximum) 

92.4 

60.4 

60.4 

54.2 

40.3 

36.1 

22.9 

17.4 

11.1 

7.6 

7.6 

7.6 

2.1 

2.1 

5.5 

1 - 60 

AWWs submitting the records/registers to health department 28.7 (43) 

Person to whom AWW submit the records to* 

Anganwadi supervisor 

ANM 

MO PHC 

No one 

Other (CDPO/DPO) 

Person who checks/supervises the records/registers that are maintained by AWW* 

Anganwadi supervisor 

ANM 

MO PHC 

Other (CDPO/DPO) 

No response 

83.7 

7.0 

4.7 

7.0 

11.6 

AWWs who receive feedback from supervisor on the data maintained or provided by them 95.3 (41) 


Visits by district or block officials in the past 3 months 

Yes, visited while I was present 

Yes, visited but I was not there 

No, did not visit in past 3 months 

No, visited more than 3 months back 

Never visited since I started working here 

93.0 

7.0 

2.3 

9.3 

2.3 

21.3 

1.3 

44.7 

4.7 

28.0 

Percent of AWWs ever visited by district/block officials 72.0 (108) 

Percent informed in advance about the last visit of block/district officials 17.6 (19) 


81

Appendix-1 

Table A34: Knowledge and opinion of AWWs about their work with the government in Himachal Pradesh, 

2007 

Percentage 


Knowledge about the objective of Government in “implementing” JSY * 

To provide benefits for poor people 

To promote institutional delivery 

Reduce maternal and child mortality 

Create awareness on health in the community 

Immunization coverage 

Improve mother’s health 

Safe delivery to save the child 

Improve community health 

Social development 

Population control 

Improve mother’s health through ANCs 

Tuberculosis control program 

Others 

Do not know 

AWWs perception on the utilization of their knowledge 

Well utilized 

Somewhat utilized 

Under utilized 

Respondents that felt that they require more training to be a good Anganwadi worker 

Yes 

Maybe 

No 

I cannot say 

AWWs that thought that JSY is useful 94.7 

Reasons for opining that JSY is useful or not useful* 

Poor people get cash benefits 

Women get health related information 

BPL women can also have institutional delivery 

It is a facility for people 

Institutional delivery is better in reducing maternal and child mortality 

Pregnant women get benefits 

For nutrition 

Do not know / cannot say 

Extent to which the community avails of JSY * 

Now most of the people are aware of JSY/most of the people get JSY benefit 

Some 40 – 70 percent people avail of JSY / not all 

People who know about JSY use it 

Those who got cash assistance 

Avails JSY for nutrition 

Only BPL families get benefit / people under IRDP get benefit 

Users / beneficiaries informed the relatives to utilize JSY and get benefits 

Do not know / cannot say 

Respondents mentioning services that they as AWWs would like to provide but not providing 

currently 

82 

50.7 

44.0 

34.7 

26.7 

25.3 

18.7 

17.3 

12.0 

11.3 

5.3 

4.7 

0.7 

3.3 

12.7 

90.7 

8.7 

0.7 

69.3 

22.7 

5.3 

2.7 

69.3 

14.7 

7.3 

6.7 

5.3 

4.0 

3.3 

5.3 

53.3 

14.7 

14.0 

4.7 

2.7 

2.7 

1.3 

9.3 

20.7 (31) 

Contd..

Type of services AWWs would like to provide* 

Give BPL card to all eligible 

Ensure advance money for ANCs to mother 

Give necessary aids/medicine to poor women 

Ensure that women get money quickly 

Ensure that home deliveries are stopped/motivate for institutional delivery 

First aid services 

Propagate JSY 

Should have a vehicle 

Benefits for widows/orphans 

Provide care for minor ailments 

Build latrine in poor people’s houses 

Specialist doctor should check all the women coming for ANCs 

Teach the girls how to tailor but there is no tailoring centre 

Others 

Do not know 


Appendix-1 

Table A35: Suggestions of AWW for further strengthening their work in Himachal Pradesh, 2007 

Percentage 


Respondents that provided suggestion for improving JSY 78.7 (118) 

Suggestions made by AWWs for improving their work and JSY* 

Cash assistance should be more 

Should give complete information 

Some officials/doctors/nurse should come and talk to the village people to explain JSY 

More propagation/advertisements on television/newspaper/camp/rally 

More incentive for sterilization 

Lady doctor should be there 

Dai should be trained 

Should get dai kit 

Facilities should be improved 

Should use posters/role play/drama for training AWW 

Good behaviour with women at the place of delivery 

Arrangement of transportation/van 

Health system should deal with myths and misconceptions 

Should get monthly payment 

Should get joining letter soon 

Should get good/practical training for AWW 

Others 


83 

48.4 

29.0 

29.0 

25.8 

22.6 

22.6 

12.9 

9.7 

9.7 

6.5 

3.2 

3.2 

3.2 

19.4 

3.2 

66.1 

61.9 

41.5 

37.3 

28.8 

23.7 

20.3 

12.7 

11.0 

10.2 

8.5 

7.6 

7.6 

5.1 

4.2 

4.2 

2.5

Appendix-1 

Table A36: Difficulties and challenges faced by AWW in carrying out activities in Himachal Pradesh, 2007 

Percentage 


AWWs voicing challenges faced by them 67.3 (101) 

Challenges faced by AWW* 

Village people are not ready for institutional delivery 

Opposition from community/illiterate people 

Opposition by family members of the women 

Women are not ready to take IFA tablets 

My husband/family does not like my job 

Too much work and little money/salary is to low for the work we have to do 

I do not get money on time so I have to listen to complains from the community 

Women do not listen regarding child immunization 

Distance to the homes/accessibility 

Seniors at work do not allow us to work/move forward 

Women do not listen regarding weighing the baby 

Cases motivated by us are registered by ANM 

No permanent centre/non availability of helper 

ANM does not allow us to work without joining letter 

Others 

Do not know 


84 

43.6 

32.7 

25.7 

22.8 

20.8 

13.8 

11.9 

10.9 

10.0 

8.9 

7.0 

3.0 

1.9 

1.0 

4.9 

7.9

Appendix 2 

JSY Tables 

Coverage of sample in Himachal Pradesh, 2007 


Total 

Institution At home 

N % N % N % 

JSY beneficiaries interviewed 113 100.0 124 100.0 237 100.0 

District name Block name 

Shimla Sunni 26 23.0 10 8.1 36 15.2 

Mashobara 24 21.2 11 8.9 35 14.8 

Una Amb 19 16.8 15 12.1 34 14.3 

Gagret 17 15.0 29 23.4 46 19.4 

Chamba Pukhari 21 18.6 30 24.2 51 21.5 

Tissa 6 5.3 29 23.4 35 14.8 

Table J1: Background information of JSY beneficiary, Himachal Pradesh, 2007 (Percentage) 

Institution At home Total 

Total number of JSY beneficiaries interviewed 113 124 237 

Age of JSY beneficiary in completed years 

≤ 19 years 

20 – 24 years 

25 – 29 years 

30 – 34 years 

35 – 39 years 

Mean (age in years) 

Years of schooling completed 

No formal education 

Up to primary (5th std) 

Middle (6–8 std) 

Secondary (9–10 std) 

Higher secondary (11–12 std) 

Undergraduate and above 

Mean (years of completed education) 

Religion 

8.8 

6.0 7.3 

Hindu 

96.5 98.4 97.5 

Muslim 

Caste 

3.5 

1.6 2.5 

Scheduled caste 

54.0 54.8 54.4 

Scheduled tribe 

3.5 

8.1 5.9 


3.5 

6.5 5.1 

General 

38.1 29.8 33.8 

Do not know 

0.9 

0.8 0.8 

Average monthly family income (In Rs.) 

Mean number of living sons and daughters 

1823.9 1453.1 1635.1 

Living sons 

0.7 

0.7 0.7 

Living daughters 

0.6 

0.8 0.7 

Living children 

1.3 

1.6 1.4 

2.7 

67.3 

23.9 

4.4 

1.8 

23.8 

4.4 

13.3 

27.4 

34.5 

15.0 

5.3 

4.0 

65.3 

26.6 

4.0 

0.0 

23.4 

18.5 

31.5 

24.2 

22.6 

2.4 

0.8 

3.4 

66.2 

25.3 

4.2 

0.8 

23.6 

11.8 

22.8 

25.7 

28.3 

8.4 

3.0

Appendix-2 

Table J2: Source and type of information regarding JSY in Himachal Pradesh, 2007 (Percentages) 



Time when JSY beneficiary heard about JSY 

Before pregnancy 

During pregnancy 

After delivery 

Cannot say/ do not remember 

Source of information about JSY* 

ANM 

Anganwadi Centre/Worker 

Doctor 

Hoardings at SC/PHC etc. 

Radio 

Relatives 

TV 

Gram Panchayat 

Pamphlets 

Others users of JSY 

Neighbour 

Others 

Do not remember 

Information about the nature of services of JSY* 

Get/receive money 

Benefit of child/to take care of newborn child 

Advice for intake of nutritious food 

Promotion of institutional delivery 

Benefit of mother 

Free institutional deliver services for poor women with some cash 

assistance 


Population stabilization 

For poor family 

Discouraging home delivery 



86 

14.2 

48.7 

31.0 

6.2 

43.4 

37.2 

26.5 

6.2 

6.2 

4.4 

4.4 

3.5 

0.0 

0.0 

0.0 

0.9 

6.2 

44.2 

38.9 

37.2 

37.2 

19.5 

15.9 

15.0 

2.7 

2.7 

0.9 

9.7 

14.5 

54.0 

22.6 

8.9 

52.4 

35.5 

19.4 

4.0 

2.4 

3.2 

2.4 

0.0 

0.8 

0.8 

0.8 

0.0 

8.1 

44.4 

37.1 

27.4 

22.6 

16.9 

19.4 

7.3 

1.6 

0.0 

0.8 

12.1 

14.3 

51.5 

26.6 

7.6 

48.1 

36.3 

22.8 

5.1 

4.2 

3.8 

3.4 

1.7 

0.4 

0.4 

0.4 

0.4 

7.2 

44.3 

38.0 

32.1 

29.5 

18.1 

17.7 

11.0 

2.1 

1.3 

0.8 

11.0

Appendix-2 

Table J3: Process of registration, Himachal Pradesh, 2007 (Percentages) 



Percent JSY beneficiary approached someone or someone approached her for 

JSY registration 

Yes, I approached someone 

Yes, someone approached me 

No registration 


No response 

Person who registered respondent for JSY 

ANM/FHW 

Doctor 

Anganwadi worker 

LHV 

Others 


Stage of pregnancy when woman got registered for JSY 

First trimester 

Second trimester 

Third trimester 

After delivery 

Do not know 


Place where respondent was registered 

Sub-centre 

PHC 

Anganwadi centre 

Community Health Centre 

District/sub-district hospital 

At home 

Panchayat 

Others 


69.9 

15.0 

1.8 

12.4 

0.9 

56.7 

21.6 

11.3 

0.0 

8.2 

2.1 

21.6 

36.1 

19.6 

19.6 

3.1 

4.8 

55.7 

21.6 

8.2 

1.0 

5.2 

3.1 

3.1 

2.0 

66.9 

11.3 

4.0 

15.3 

2.4 

69.0 

9.0 

17.0 

2.0 

0.0 

3.0 

19.0 

31.0 

19.0 

21.0 

10.0 

5.2 

52.0 

18.0 

14.0 

11.0 

2.0 

1.0 

0.0 

2.0 

68.4 

13.1 

3.0 

13.9 

1.7 

62.9 

15.2 

14.2 

1.0 

4.1 

2.5 

20.3 

33.5 

19.3 

20.3 

6.6 

5.0 

53.8 

19.8 

11.2 

6.1 

3.6 

2.0 

1.5 

2.0 

Table J4: Awareness about index pregnancy, Himachal Pradesh, 2007 (Percentages) 




Month of index pregnancy when mother realized that she was pregnant 

≤ 2 months 

3 rd month 

4 th month or later 

Do not know 


2.5 2.5 2.5 

Percent who confirmed pregnancy through testing 94.7 87.9 91.1 

87 

58.4 

32.7 

7.1 

1.8 

54.8 

34.7 

10.5 

0.0 

56.5 

33.8 

8.9 

0.8

Appendix-2 

Table J5: Contact with health personnel during index pregnancy in Himachal Pradesh, 2007 (Percentages) 



Percent contacted by someone (from health department) or self contacted 

health personnel during last pregnancy 

Somebody from health department contacted 

JSY beneficiary contacted somebody 

No contact made 

26.5 

68.1 

5.3 

Number of JSY beneficiaries who had contact with health personnel 94.6 

(107) 

Stage of pregnancy when first contact was made 

≤ 2 months 

3 rd month 

4 th month 


Do not know 


Person with whom first contact was made 

Doctor 

LHV 

ANM/FHW 


Percent advised by the health personnel for antenatal check-up 

Yes, advised for ANC 

No, not advised 


34.6 

44.9 

5.6 

15.0 

0.0 

3.1 

59.8 

0.0 

39.3 

0.9 

97.2 

0.9 

1.9 

33.1 

54.8 

12.1 

87.9 

(109) 

26.6 

34.9 

19.3 

18.3 

0.9 

3.4 

48.6 

1.8 

48.6 

0.9 

97.2 

1.8 

0.9 

30.0 

61.2 

8.9 

91.2 

(216) 

30.6 

39.8 

12.5 

16.7 

0.5 

3.3 

54.2 

0.9 

44.0 

0.9 

Table J6: Frequency and place of antenatal check-ups during index pregnancy, Himachal Pradesh, 2007 

(Percentages) 



Women who availed any antenatal check-up during index pregnancy 98.2 

(111) 

Month of pregnancy when availed antenatal care services for the first time 

≤ 2 months 




Do not know 


Number of times mother underwent antenatal check-ups 

1 time 

2 times 

3 times 

4 or more 

Mean (number of times) 

Place from where women received antenatal care services * 



PHC 

Subcentre 

Private hospital / Private hospital accredited by the government 

At home 

Anganwadi centre 


88 

29.7 

45.9 

11.7 

11.7 

0.9 

3.6 

8.1 

9.9 

23.4 

58.6 

4.3 

57.7 

6.3 

14.4 

27.9 

9.0 

0.9 

1.8 

92.7 

(115) 

22.3 

46.4 

11.6 

17.0 

2.7 

4.1 

18.3 

15.6 

33.9 

32.2 

3.2 

10.4 

19.1 

16.5 

35.7 

5.2 

31.3 

4.3 

97.2 

1.4 

1.4 

95.4 

(226) 

26.0 

46.2 

11.7 

14.3 

1.8 

3.8 

13.3 

12.8 

28.8 

45.1 

3.7 

33.6 

12.8 

15.5 

31.9 

7.0 

16.4 

3.1

Appendix-2 

Table J7: Persons who motivated JSY beneficiaries for antenatal check-ups in Himachal Pradesh, 2007 

(Percentages) 



Percent influenced or motivated by someone to avail antenatal check-up 95.5 

(106) 

Persons who influenced or motivated respondent’s decision to go for 

antenatal check-up * 

Husband 

Self motivated 

Mother-in-law 

LHV/ANM/FHW 

Other family members/relatives/friends 


Doctor 

Dai 


79.2 

51.9 

52.8 

14.2 

17.0 

11.3 

9.4 

0.9 

93.0 

(107) 

72.9 

59.8 

48.6 

15.0 

12.1 

11.2 

4.7 

0.0 

94.2 

(213) 

76.1 

55.8 

50.7 

14.6 

14.6 

11.3 

7.0 

0.5 

Table J8: Persons who accompanied the beneficiary and cost incurred for ANC visits in Himachal Pradesh, 

2007 (Percentages) 


Number of JSY beneficiaries who availed any antenatal check-up 111 115 226 

Persons who accompanied JSY beneficiary for ANC visit(s) * 


Mother-in-law 

Sister-in-law 

Mother 

Brother/father/other males 

Sister 

Anganwadi worker/Anganwadi Sahyogini 

No one 

Cost incurred (including fees, laboratory test) during ANC period 

No expense 

< 100 rupees 

101- 200 rupees 

201 - 400 rupees 

401 - 1000 rupees 

1001 or more rupees 

Do not know 

Mean (in rupees among those who incurred expenses) 

1522.9 688.1 1231.1 

Percent received cash assistance for antenatal care 

Amount received as cash assistance for antenatal care 

35.2 (31) 26.7 (12) 32.3 (43) 

Mean (in rupees among those who received cash assistance) 


611.5 466.7 500.0 

89 

80.9 

38.2 

20.9 

8.2 

6.4 

1.8 

0 

1.8 

17.3 

4.5 

2.7 

5.5 

26.4 

21.8 

21.8 

58.8 

32.5 

12.5 

3.8 

0 

2.5 

2.5 

11.3 

37.5 

7.5 

5.0 

11.3 

16.3 

5.0 

17.5 

71.6 

35.8 

17.4 

6.3 

3.7 

2.1 

1.1 

5.8 

25.8 

5.8 

3.7 

7.9 

22.1 

14.7 

20.0

Appendix-2 

Table J9: Reasons for not seeking ANC services in Himachal Pradesh, 2007 (Percentages) 



JSY beneficiaries who did not avail antenatal care services during index 

pregnancy 

1.8 (2) 7.3 (9) 4.6 (11) 

Reasons for not seeking any antenatal care services * 

Not necessary 

A high cost 

Family did not allow 

Facilities are too far/no transport 

Lack of knowledge 

Others 


Table J10: Role of AWW to JSY beneficiary during index delivery in Himachal Pradesh, 2007 (Percentages) 



Type of help provided by AWW to JSY beneficiary * 

Providing IFA tablets 

Accompanied to ANM for check-up 

Accompanied to hospital for delivery 

Did follow-up 

Visited in post-partum period 

Arranged transport 

Gave money for transport 

Registration of birth of the newborn 

Helped in immunizing the newborn 

Percent who received advice from AWW at least once during the index 

pregnancy* 

Diet 

Danger signs 

Delivery care 

Breastfeeding 

Newborn care 


Percent who were informed about the following during the antenatal period* 

Date of next check-up 

Place of next check-up 

Date of expected delivery 


Place of referral, if complications arise 


90 

50.0 

0.0 

0.0 

0.0 

0.0 

50.0 

73.5 

23.0 

14.2 

25.7 

21.2 

12.4 

24.8 

44.2 

48.7 

77.0 

50.4 

61.9 

68.1 

66.4 

50.4 

82.3 

80.5 

81.4 

71.7 

48.7 

77.8 

33.3 

22.2 

11.1 

11.1 

0.0 

64.5 

17.7 

2.4 

15.3 

11.3 

0.8 

5.6 

51.6 

52.4 

60.5 

38.7 

48.4 

54.0 

49.2 

37.1 

74.2 

65.3 

66.1 

54.8 

28.2 

72.7 

27.3 

18.2 

9.1 

9.1 

9.1 

68.8 

20.3 

8.0 

20.3 

16.0 

6.3 

14.8 

48.1 

50.6 

68.4 

44.3 

54.9 

60.8 

57.4 

43.5 

78.1 

72.6 

73.4 

62.9 

38.0

Appendix-2 

Table J11: Intentional and actual place of delivery of JSY beneficiaries in Himachal Pradesh, 2007 

(Percentages) 

Total 

Total number of JSY beneficiaries interviewed 237 

Place where respondent intended to deliver the index child 



PHC 

Sub-centre 

Private hospital 

Private hospital accredited by the Government 

At home 

Place where delivery took place 



PHC 


Private hospital accredited by the Government 

At home 

Others 

Percent who delivered at an institution 47.7 (113) 

Motivation for opting for institutional delivery * 

Safe delivery of child/safety of both mother and child 

Better access to institutional delivery services in the area 

Money available under JSY 

Complicated delivery/health problems/ white discharge 

Support provided by Anganwadi worker 

Support provided by health personnel 

A institutional birth of previous child 

Availability of transport assistance 

Previous history of child is not surviving/miscarriage/caesarian section 

Others 

Person who finally decided for institutional delivery * 


Self 

Mother in law 

Father in law 

Relatives/neighbours/users of JSY 

Anganwadi worker/Anganwadi helper/SHG member 

Friends 

ANM 

Others 


Table J12: Intentional versus actual place of delivery, Himachal Pradesh, 2007 (Percentage) 

Place where last delivery of JSY beneficiary took place 


Intended place for last delivery 

Institutional 

At home 

32.5 (77) 

15.2 (36) 

7.6 (18) 

44.7 (106) 

32.9 

2.1 

3.0 

0.8 

0.8 

0.4 

59.9 

34.2 

3.8 

3.0 

5.5 

0.8 

52.3 

0.4 

77.0 

30.1 

25.7 

17.7 

11.5 

6.2 

3.5 

2.7 

2.7 

2.7 

89.4 

73.5 

53.1 

26.5 

20.4 

7.1 

4.4 

0.9 

0.9 

40.1 (95) 

59.9 (142) 

Total 47.7 (113) 52.3 (124) 100.0 (237) 

91

Appendix-2 

Table J13: Rationale for choosing place of delivery, Himachal Pradesh, 2007 (Percentage) 

Total 

Number of JSY beneficiaries who intended to deliver at home but delivered in an institution 36 

Reasons for preferring institutional delivery despite intention to deliver at home* 

Due to complications decided to go to the hospital/(bache dani ka muh band tha is liye 

hospital jana pada) 

For the safety of both mother and child 

Relatives motivated to go for institutional delivery 

TBA is not available in this village 

More facilities at the institution 

It was past due delivery date and so I shifted to the institution 

Complicated delivery so dai referred to hospital 

Fear to going to hospital, do not want caesarean 

Do not know 

2.8 

Number of JSY beneficiaries who intended to deliver at an institution but delivered at home 18 

Reasons for preferring home delivery despite intention to deliver at an institution * 

Did not have time to reach the hospital 

On account of poverty 

Opposition from family members 


Unavailability of transport facility when required 

Dai did not allow me to go to the hospital 

Prefer home delivery by dai/Dai easily available 

Others 

Table 14: Shift in the place of delivery before and after JSY , Himachal Pradesh, 2007 (Percentage) 

Place of delivery for last (JSY) child 

Institutional Home Total 

Place of delivery for last but one child 

Institutional 

Home 

24.0 (24) 

11.0 (11) 

19.0 (19) 

46.0 (46) 

58.3 

13.9 

11.1 

5.6 

2.8 

2.8 

2.8 

2.8 

50.0 

16.7 

16.7 

11.1 

5.6 

5.6 

5.6 

5.6 

43.0 (43) 

57.0 (57) 

Total 35.0 (35) 65.0 (65) 100.0 (100) 

92

Appendix-2 

Table J15: Process of arranging transport to reach health institution, Himachal Pradesh, 2007 (Percentages) 

Total 

Number of JSY beneficiaries who delivered in an institution 113 

Percent who directly came from home to the ultimate place of delivery 93.8 

Average distance to the ultimate place of delivery from respondent’s residence (in kms) 

Range (in km) (Minimum - Maximum) 

Do not know (%) 

Mode of transport used to reach the ultimate place of delivery * 

Car/Jeep 

Bus 

Walking 

Ambulance 

Persons who facilitated in arranging transport * 

Family members 


Relatives/neighbour/cousin brother 

ANM/health worker 

Others 

Do not know 

Average time taken to arrange the transport since respondent decided to visit the ultimate place 

of delivery (in minutes) 

Range (Minimum - Maximum) 

Do not know/cannot say (%) 

22.4 

0 – 200 

15.0 

84.1 

13.3 

8.0 

0.9 

92.6 

4.6 

2.8 

0.9 

1.9 

0.9 

39.6 

1 – 240 

13.0 

Percent mentioning that arrangement for transport was pre-planned 15.7 

Average travel time taken to reach the ultimate place of delivery (from the time the transport 

facility reached the respondent) (in minutes) 



Average cost incurred for transport to reach the ultimate place of delivery (in rupees) (N=91) 


Do not know (%) 

70.7 

10 – 240 

12.0 

528.6 

24 – 2400 

15.7 

Percent who said they had private funds to pay for the transport expenses 52.8 

Table J16: Process of arranging money to pay for the transport to reach the institution, Himachal Pradesh 

(Percentage) 

Total 

Number of JSY beneficiaries who used transport to reach the institution 104 

Type of arrangement of money for transport * 

Borrowed money from someone to pay for transport 

Borrowed money from relatives/friend/from uncle/father in law 

Took loan from someone to pay for transport 

Paid by self/Self Arrangement 

Borrowed money from neighbour/villagers 

Percent given advanced money for transport expenses or reimbursed by AWW/health personnel * 

Paid by self 

Reimbursed later 

Advance money for transport given 

Average amount received for transport assistance among those who received cash assistance (in 

Rupees) (n=27) 


93 

59.3 

23.1 

13.0 

7.4 

7.4 

69.4 

20.4 

10.2 

544.3

Appendix-2 

Table J17: Difficulties faced in reaching the place of delivery, Himachal Pradesh, 2007 (Percentages) 

Total 


Percent given a referral slip to help them access delivery services by AWW or health personnel 16.8 

Percent who had any difficulty in reaching the health institution 13.3 (15) 

Types of difficulties faced in reaching the health institution * 

Transport was not immediately available 

It was late in the night 

Did not have sufficient money 

Male members in household were not present 


53.3 

46.7 

46.7 

6.7 

Table J18: Persons accompanying JSY beneficiaries to the health institution in Himachal Pradesh, 2007 

(Percentages) 

Total 

Number of JSY beneficiaries that delivered in an institution 113 

Timing of the day when JSY beneficiary reached the place of delivery 

6 AM – 12 PM 

12 PM – 6 PM 

6 PM – 12 AM 

12 AM – 6 AM 

Persons who accompanied the JSY beneficiary to the health institution * 


Mother in law 

Other family members 

Mother 

Neighbour or other 


Dai/TBA 

ANM/health worker 

Government doctor 

Number mentioned that presence of Anganwadi worker facilitate in obtaining services 2 

Number JSY beneficiaries mentioned about facilitation done by Anganwadi worker 

Spoke to the medical personnel 

Helped in expediting registration and other administrative activities 


94 

24.8 

36.3 

26.5 

12.4 

85.8 

59.3 

43.4 

20.4 

5.3 

1.8 

3.5 

3.6 

1.8 

1 

1

Appendix-2 

Table J19: Quality of services available at the place of delivery in Himachal Pradesh, 2007 (Percentages) 

Total 

Number of JSY beneficiary that delivered in an institution 113 

Average time taken to complete the administrative or registration process at the 

ultimate place of delivery (in minutes) 



Average waiting time at the facility until someone attended the JSY beneficiary (in 

minutes) 



Type of delivery 

Normal 

Assisted (Forceps, Ventouse, Vacuum) 

Caesarean 

Person who conducted the delivery 

Doctor 

ANM/nurse/LHV 

Others 

Do not know 

Average (and range) hours after delivery when woman was discharged 

Normal delivery (n=89) 

Assisted (forcep, ventouse, vacuum) (n=3) 

Caesarean (n=21) 

26.7 

1 – 150 

27.4 

35.0 

1 – 240 

2.7 

78.8 

2.7 

18.6 

54.9 

39.8 

0.9 

4.4 

30.4 (2 - 240) 

24.0 ( 24 ) 

119.0 ( 24-288) 

Table J20: Payments made for services at the health center in Himachal Pradesh, 2007 (Percentages) 

Total 


Percent who had to pay for services at the health centre 82.3 (93) 

Specific services for which beneficiaries were charged 

Delivery/caesarean /Operation charge 

Accommodation charge 

Medicines/IV fluids 

Food charges 

Laboratory test 

Paediatric care 

Diagnostic/sonography 

Average amount spent for the index delivery (in rupees) 


Do not know 

95 

61.3 

55.9 

91.4 

44.1 

52.7 

33.3 

19.4 

3732.9 

50-22000 

17.6

Appendix-2 

Table J21: Satisfaction with the services at the place of delivery in Himachal Pradesh, 2007 (Percentages) 

Total 


Percent satisfied with the services available at the place of delivery 97.3 (110) 

Nature of satisfaction/dissatisfaction expressed* 

Health facility was clean 

Health staff and doctors were courteous 

Counselled for breastfeeding/immunization 

Counselled about follow-up visit 

Counselled for family planning 

Counselled for newborn care, diarrhoea management 

Hospital provided good and sufficient services 

Facility was not clean/adequate 

Staff was rude 

Others 

No response 


Table J22: Improvements necessary at the institution in Himachal Pradesh, 2007 (Percentage) 

Total 

Number of JSY beneficiaries that delivered in the institution 113 

JSY beneficiaries who are satisfied with the present facility 97.3 (110) 

Conditions beneficiaries feel need improvement 

All things are OK/I am satisfied 

Need more doctors/doctors should be available more frequently and spend more time with the 

patient 

Improve the services/sitting arrangement in the facility 

Treatment in hospital should be either free or low in cost 

Need for doctors and health staff with good and courteous behaviour 

Facility should have clean bathrooms and toilets 

Facility should provide good quality medicine in time 

Hospital should have more rooms/wards 

Government should give the money in advance/increase the assistance 

Hospital should have adequate number of beds 

Demand of nutritious food / should provide nutritious food / fruit and milk 

Others 

Do not know 

96 

85.0 

55.8 

33.6 

30.1 

15.9 

7.1 

1.8 

3.5 

0.9 

1.8 

3.5 

33.6 

12.4 

8.0 

6.2 

4.4 

2.7 

1.8 

1.8 

1.8 

0.9 

0.9 

0.9 

31.0

Appendix-2 

Table J23: Rationale for JSY beneficiaries to deliver at home and information they had regarding institutional 

delivery 

Percentage 

Number of JSY beneficiaries who delivered at home 124 

Percent of beneficiaries who had discussed institutional delivery as an option 58.9 (73) 

Reasons for households to opt for home delivery * 

Get better care at home 


Fear of doctor / nurse 

No necessity of institutional delivery 

Fear of going to hospital/needle / injection / equipment 

Prefer home delivery 

Home delivery is cheaper 


Dai takes better care while assisting delivery 

Fear of caesarean section/stitches 

Go to hospital only if complication arise 

Emergency/no time to go to the hospital 

Unavailability of transport facility on time 

First delivery is preferred at home 

Dai does not allow me to go to the hospital 

Do not know 

Person who finally decided for home delivery * 

Self 


Mother in law 

Father in law 

Relatives / neighbours / users of JSY 

Anganwadi 

Others 

32.3 

25.8 

24.2 

21.8 

18.5 

18.5 

16.1 

12.9 

11.3 

11.3 

5.6 

4.8 

4.0 

4.0 

3.2 

2.4 

82.3 

49.2 

47.6 

25.0 

16.9 

1.6 

1.6 

JSY beneficiaries who received information about the benefits of institutional delivery during their 

last pregnancy and who ultimately delivered at home 54.8 (68) 

Person who explained the benefits of institutional delivery 

Doctor 

LHV/ANM/Nurse 

TBA 

Friends/Relatives 

Others 

Type of benefits explained 

Institutional delivery means safety and care for both mother and child 

Better services at the hospital 

Will receive cash assistance 

There will be follow up visits/check ups 

Get medicine 

Do not know 

No response 

Percent of beneficiaries that are aware of an additional Rs 200 assistance provided in case of 

institutional delivery 

Percent among those who delivered at home and experienced complications just before or 

during delivery 

Type of complications 

Premature labour 

Excessive labour 

Prolonged labour 

Obstructed labour 

Breech presentation 

Excessive white discharge 

Health problems/vomiting/feeling uneasy/physically weak 

Excessive bleeding/vaginal bleeding 

There was problem in the uterus Bache dani me kuch problem create ho gaya tha./Bache dani ka 

muh band tha 


97 

17.6 

77.9 

1.5 

13.2 

8.8 

38.2 

35.3 

29.4 

5.9 

1.5 

2.9 

10.3 

30.6 (38) 

35.5 (44) 

6.8 

65.9 

11.4 

15.9 

6.8 

45.5 

11.4 

2.3 

2.3

Appendix-2 

Table J24: Persons who assisted delivery at home, Himachal Pradesh, 2007 (Percentages) 

Total 

Number of JSY beneficiaries who delivered at home 124 

Persons who assisted the delivery * 

Doctor 

LHV/ANM/Nurse 

TBA 

Friends/Relatives 

No response 


Table J25: Views about TBA, Himachal Pradesh, 2007 (Percentages) 



Percent opined that TBA can provide all necessary midwifery services 13.3 (15) 42.7 (53) 28.7 (68) 

Reasons for saying that TBA can provide necessary midwifery services * 

TBA is easily accessible 

TBA has better knowledge of the cultural practices and follows it 

TBA charges less money 

Better comfort level with TBA 

By tradition TBA has been conducting deliveries in the family 


98 

73.3 

33.3 

20.0 

33.3 

6.7 

69.8 

45.3 

41.5 

18.9 

17.0 

1.6 

8.1 

87.1 

26.6 

2.4 

70.6 

42.6 

36.8 

22.1 

14.7

Appendix-2 

Table J26: Perceived reasons for women to deliver at home despite cash assistance paid under JSY for 

institutional delivery, Himachal Pradesh, 2007 (Percentages) 



Reasons for preferring home delivery * 



There are expenses in the hospital/home delivery is cheaper 

Fear of doctor/nurse 

Clinic located far away 

Fear of emergency 

Dai (TBA) takes better care while assisting delivery 

Dai opposes if women go to the hospital 

Prefer home delivery by dai 

False medicine are used which cause the child to die 

Unaware of JSY 

Do not understand importance of institutional delivery 


If the doctor says everything is normal then they prefer home delivery 

Opposition from family member 

Unavailability of transport facility in time 

I did not get money so I did not prefer institutional delivery 

Roads are bad so prefer home delivery 

Did not get time to go to the hospital 

Staff is not cooperative/rude 

Lady doctor not available in hospital 

No proper care of patient in the hospital 

Nobody at home to accompany me to go to the hospital 

Have to stay many days at the hospital 

Others 

Do not know 


17.7 

14.2 

13.3 

14.2 

13.3 

9.7 

7.1 

8.0 

4.4 

8.0 

4.4 

8.0 

1.8 

0.9 

1.8 

0.9 

0.9 

- 

0.9 

0.9 

1.8 

1.8 

- 

- 

0.9 

20.4 

29.8 

14.5 

12.1 

10.5 

10.5 

8.1 

4.8 

4.0 

7.3 

3.2 

5.6 

1.6 

6.5 

4.8 

4.0 

3.2 

3.2 

2.4 

1.6 

1.6 

0.8 

0.8 

0.8 

0.8 

1.6 

21.8 

Table J27: Background information of JSY beneficiaries, Himachal Pradesh, 2007 (Percentage) 

Institution 

Education 

At home Total N 

No formal education or up to primary 

24.4 75.6 82 

Middle level or more 

60.0 40.0 155 

Percent belonged to 

Scheduled caste / Scheduled tribe 

45.5 54.5 143 


33.3 66.7 12 

General 

53.8 46.3 80 

Do not know 

50.0 50.0 

2 

Average monthly family income (In Rs.) 1823.9 1453.1 1635.1 

Table J28: Contact with health personnel during index pregnancy by place of delivery, Himachal Pradesh, 

2007 (Percentage) 


Percent contacted by someone from health department during last pregnancy 26.5 33.1 30.0 

Among those contacted during pregnancy, percent first contacted by 

LHV/ANM/FHW 

39.3 50.4 44.9 

Percent of respondents who were influenced or motivated to go for antenatal 

check-up by LHV/ANM/FHW/AWW 

25.5 26.2 25.9 

Percent JSY beneficiaries accompanied by AWW for ANC visit(s)* 0.0 2.5 1.1 

Percent JSY beneficiaries approached by someone for JSY registration 15.0 11.3 13.1 

Percent registered by LHV/ANM/FHW/AWW for JSY 68.0 88.0 78.1 


99 

24.1 

14.3 

12.7 

12.2 

11.8 

8.9 

5.9 

5.9 

5.9 

5.5 

5.1 

4.6 

4.2 

3.0 

3.0 

2.1 

2.1 

1.3 

1.3 

1.3 

1.3 

1.3 

0.4 

0.4 

1.3 

21.1

Appendix-2 

Table J29: Utilization of ANC services during index pregnancy by place of delivery, Himachal Pradesh, 2007 

(Percentages) 


Percent first contacted in 1 st trimester 79.5 61.5 70.4 

Percent who had 3 or more antenatal check-ups 82.0 66.1 73.9 

Percent incurred any expenses for receiving antenatal check-ups 80.0 56.3 70.0 

Average amount spent during ANC period including fees, laboratory test 1522.9 688.1 1231.1 

Percent heard about the JSY after delivery 31.0 22.6 26.6 

Total number of JSY beneficiaries interviewed 

Place where received antenatal care* 

113 124 237 

District/sub-district hospital/CHC/PHC 

78.4 46.0 61.9 

Sub-centre/ Anganwadi centre 

29.7 40.0 35.0 

Private hospital / Private hospital accredited by the government 

At home 

Place where respondent was registered 

District/sub-district hospital/CHC/PHC 

Sub-centre/Anganwadi centre/ Panchayat 

Others/at home 

Table J30: Payment made to JSY beneficiaries for delivery in Himachal Pradesh, 2007 (Percentages) 



Percent received JSY cash assistance 85.0 (96) 68.5 (85) 76.4 (181) 

Instalment of payment for JSY cash assistance 

In one go 

In instalments 

Time when JSY beneficiary received the money 

At the time of registration 

At time of antenatal check-ups 

Much before the delivery 

Within a week before the EDD 

Immediately after the delivery 

Within a week after the delivery 

Much later 

Others 

Person who gave the cash assistance to JSY beneficiary 

ANM 

CHC/PHC MO 

MHW 

At health centre 

Anganwadi 

Accountant/clerk 

Panchayat 


Other 

Do not know 

Place where received cash assistance 


At the CHC/PHC 

Sub-centre 

Anganwadi worker/anganwadi centre 

At home 

Within the village 

Others 

Average amount received by JSY beneficiary (in rupees) 

Mean 


Number of JSY beneficiaries received cash assistance 

100 

81.3 

18.8 

4.2 

7.3 

22.9 

5.2 

9.4 

20.8 

28.1 

2.1 

49.0 

24.0 

6.3 

7.3 

3.1 

3.1 

2.1 

0.0 

1.0 

4.1 

5.2 

40.6 

32.3 

1.0 

18.8 

1.0 

1.0 

683.8 

200-1200 

96 

9.0 

0.9 

27.8 

67.0 

5.1 

98.8 

1.2 

4.7 

12.9 

29.4 

5.9 

7.1 

12.9 

27.1 

0.0 

60.0 

22.4 

5.9 

3.5 

3.5 

1.2 

1.2 

1.2 

0.0 

1.2 

1.2 

51.8 

27.1 

2.4 

10.6 

4.7 

2.4 

478.0 

100-500 

84 

5.2 

31.3 

31.0 

66.0 

3.0 

7.0 

16.4 

29.5 

66.5 

4.0 

89.5 

10.5 

4.4 

9.9 

26.0 

5.5 

8.3 

17.1 

27.6 

1.1 

54.1 

23.2 

6.1 

5.5 

3.3 

2.2 

1.7 

0.6 

0.6 

2.8 

3.3 

45.9 

29.8 

1.7 

14.9 

2.8 

1.8 

587.8 

100-1200 

180

Appendix-2 

Table J31: Difficulties faced by JSY beneficiaries in getting cash assistance for delivery in Himachal Pradesh, 

2007 (Percentages) 

Total 

Number of JSY beneficiaries who received JSY cash assistance for delivery 181 

Percent faced difficulty in getting money (of those who received JSY assistance) 11.0 (20) 

Type of difficulties faced in getting money * 

Had to visit many times to get the money 

Paid in instalments 

Payment not received when needed/untimely 

No money with ANM 

No response 

Percent mentioning that the cash assistance received was sufficient to meet delivery expenses 

Sufficient 

Somewhat sufficient 

Not sufficient 

Type of utilization of money received under the JSY * 

Bought medicines/tonics for self and child 

Used on self nutrition/fruit 

Used for medical expenses for delivery 

Have not spent any money so far 

Purchased consumables for the family 

Husband took it away 

Others 

Do not know 


65.0 

25.0 

15.0 

5.0 

15.0 

44.2 

14.4 

41.4 

64.1 

61.9 

8.8 

8.3 

3.9 

1.1 

1.7 

1.7 

Table J32: Opinions of beneficiaries about JSY in Himachal Pradesh, 2007 (Percentages) 



Percent who would recommend relatives or friends/neighbours to be a 

beneficiary under JSY 

Reasons for recommending/not recommending JSY * 

Cash received on filling of the form 

JSY is beneficial and provides safety to mothers so all should use 

Hospital provides good services 

Poor people receive help 

Free/cheaper delivery 

Receive good knowledge and education 

No objection, depends on individuals 

I received the money late 

Others 

Do not know 


101 

90.3 

(102) 

41.6 

26.5 

27.4 

19.5 

0.0 

0.9 

0.0 

0.0 

0.9 

6.2 

93.5 

(116) 

54.0 

16.9 

15.3 

16.9 

2.4 

1.6 

0.8 

0.8 

0.0 

6.5 

92.0 

(218) 

48.1 

21.5 

21.1 

18.1 

1.3 

1.3 

0.4 

0.4 

0.4 

6.4

Appendix-2 

Table J33: Complications during index pregnancy, Himachal Pradesh, 2007 (Percentages) 

Total 


Percent delivered at institution who had any complications just before or during delivery 52.2 (59) 

Type of complications faced before or during delivery among those who delivered at 

institution * 

Excessive labour 

Excessive white discharge 

obstructed labour 

Prolonged labour 

Breech presentation 

Premature labour 

There was a problem in uterus / Bache dani ka muh band tha 

Health problems/vomiting/ feel uneasy/physically weak 

Other 

No response 


Table J34: Profile of last and last but one child, Himachal Pradesh, 2007 

Percentage and mean 

Last child Last but one child 

Number of mothers 237 100 

Average age of child (in months) 9.0 38.4 

Sex of the child 

Male 

Female 




PHC 

Subcentre 


Private hospital accredited by Government 

At home 

Other 

Mothers who incurred expense on the last but one 

delivery 

Institutional 

Home 

Total 

Average expense on the last but one delivery (in rupees) 

Institutional (109) 

Home (113) 

Total (222) 

51.1 

48.9 

32.9 

4.2 

3.0 

0.8 

5.1 

0.8 

52.7 

0.4 

61.0 

22.0 

18.6 

11.9 

6.8 

5.1 

3.4 

1.7 

1.7 

1.7 

43.0 

57.0 

32.0 

3.0 

2.0 

3.0 

2.0 

1.0 

57.0 

0.0 

100.0 (113) 

93.5(124) 

96.6 (237) 

1823.9 

1453.1 

1635.1 

Percent of mothers reporting that the newborn died 1.7 (4) 4.0 (4) 

Number of days child died after birth (number) 

Immediately after birth / day of delivery 

Nine days after birth 


Institution 

Home 

Causes of death (number) 

Child was born dead 

Fluid in chest 

Incomplete growth 

Do not know 

102 

4 

- 

4 

- 

1 

1 

1 

1 

2 

2 

2 

2 

- 

- 

- 

4

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