India’s Auxiliary Nurse-Midwife, Anganwadi Worker, and Accredited Social Health Activist Programs

By: Kerry Scott, Douglas Glandon, Binita Adhikari, Osama Ummer, Dena Javadi, and Jessica Gergen

Auxiliary Nurse-Midwives (ANMs), Accredited Social Health Activists (ASHAs), and Anganwadi Workers (AWWs) constitute the three cadres that make up India’s government-supported CHWs. ANMs work at health sub-centers or PHC centers and provide immunizations, health education, and antenatal care as a part of their village outreach. AWWs operate in village anganwadi (childcare) centers and conduct health and nutrition education. ASHAs conduct home-visits and assist ANMs and AWWs to promote maternal and child health. Research shows ASHAs are associated with advancements in health and care-seeking but also indicate gaps in ASHA knowledge, insufficient supervision, and weak community and referral linkage systems. Evidence on the effectiveness, impact and outcomes of ANMs and AWWs is lacking or inconclusive.

Background
India has three main cadres of government CHWs: Auxiliary Nurse-Midwives (ANMs), Accredited Social Health Activists (ASHAs), and Anganwadi Workers (AWWs). ANMs and ASHAs work within the Ministry of Health and Family Welfare, while AWWs are part of the Ministry of Women and Child Development.

Implementation
As of 2018 there were approximately 219,000 ANMs, 1.3 million AWWs, and 971,000 ASHAs. ANMs are based at health sub-centers or primary health care centers and conduct village outreach. AWWs work in their village anganwadi centers, which serve as preschools and community health and nutrition centers. ASHAs work in their villages by visiting women’s homes, providing assistance to ANMs and AWWs at community health events, and encouraging community members to go to healthcare facilities.

Roles/responsibilities
ANMs have a broad set of responsibilities, focused on providing immunization, health education, and antenatal care, as well as conducting deliveries. AWWs run preschool programs, provide supplementary food to young children, adolescent girls, and lactating women, and provide health and nutrition education to pregnant women, mothers, and adolescent girls. ASHAs promote reproductive, maternal, neonatal and child health with particular focus on encouraging immunization, institutional-based deliveries, and family planning and providing home-based newborn care and some medicines, such as oral contraceptives. They also receive incentives for malaria case identification, TB treatment support, screening for chronic, non-communicable diseases, and conducting village health committee meetings.

Training
ANMs receive 24 months of training. AWWs receive 3-4 weeks, and ASHAs receive 4-5 weeks.

Supervision
ANMs report to Lady Health Visitors and Medical Officers (i.e., doctors). ASHAs report to ASHA Facilitators and AWWs report to Anganwadi Supervisors (Mukhya Sevikas).

Incentives and remuneration
Payment varies by state; the amounts noted here are approximate. ANMs are paid a government salary that increases with seniority but averages US$ 280 per month. AWWs are considered volunteers but are paid an “honorarium” of US$ 50 – 130 per month. ASHAs receive performance-based incentives for over 64 activities, such as US$ 9 for facilitating an institutional delivery and US$ 2.50 for facilitating a child’s completion of immunizations. They also receive US$ 28 per month for satisfactory performance of routine tasks.

Impact
No impact evaluations of ANMs have been published. Assessments of the Integrated Child Development Services and its AWWs consistently note the widespread geographic coverage of the program but vary in terms of their conclusions about the program’s impact on child nutritional outcomes. The ASHA program has been associated with improvements in neonatal health, some aspects of care-seeking, and increased immunization and health-related awareness in certain areas. However, research has also identified ASHA knowledge gaps, inadequacies in ASHA training or supervision, low community engagement with and awareness of ASHAs, challenges related to referrals (limited transportation, coordination and health facility resources), and subpar performance or coverage.

Author Affiliations

• Kerry Scott is an Associate Faculty member in the Department of International Health at Johns Hopkins School of Public Health.
• Douglas Glandon is an Associate Faculty member in the Department of International Health at Johns Hopkins School of Public Health.
• Binita Adhikari is an Associate Faculty member in the Department of International Health at Johns Hopkins School of Public Health.
• Osama Ummer works at Oxford Policy Management.
• Dena Javadi works at The Alliance for Health Policy and Systems Research at the World Health Organization.
• Jessica Gergen is a CEO at Visualst.

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