Lok Sabha Question No. 2364 (UNSTARRED), answered on 2018-03-09
Subject: Sub-Centres in Public Health System
Ministry: HEALTH AND FAMILY WELFARE
Asked by: Partha Pratim Ray

## GOVERNMENT OF INDIA MINISTRY OF HEALTH AND FAMILY WELFARE DEPARTMENT OF HEALTH AND FAMILY WELFARE

LOK SABHA UNSTARRED QUESTION NO. 2364 TO BE ANSWERED ON 9 TH MARCH, 2018

## SUB - CENTRES IN PUBLIC HE ALTH SYSTEM

## 2364. SHRI PARTHA PRATIM RAY:

Will the Minister of HEALTH AND FAMILY WELFARE be pleased to state:

- (a)  whether  the  existing  sub - centres  are  sufficient  to  serve  the  public  health  system  in country;
- (b) if so, the details thereof along with the number of sub - centres presently func tioning in the country, State/UT - wise;
- (c) whether there are any job charts for Health Assistant (Female), ANM and ASHA workers a sub - centre and if so, the details thereof; and
- (d) whether the Government has any plan to increase the honorarium of AS HA workers and if so, the details thereof?

## ANSWER THE MINISTER OF STATE IN THE MINISTRY OF HEALTH AND FAMILY WELFARE (SHRI ASHWINI KUMAR CHOUBEY)

- (a) and (b):   There is some shortfall in some States/UTs in the number of sub - centres in the country.The number of sub - centres presently functioning in the country along with shortfall , State/UT - wiseis placed at Annexure - I.
- (c)Roles  and  responsibilities/job  charts  have  been  prepared  for  service  providers  at  t -center -including ANM. The IPHS Guideli nes for sub - centres (Revised 2012) lays down the rol es and responsibilities of ANMs, which are available at http://www.nhm.gov.in/nhm/nrhm/guidelines/indian - public - health - standards.html . In  addition, prototype job charts and weekly work plans have also been provided in the Ministry of H and Family Welfare 'Guidebook for enhancing performance of Multi - purpo se worker (Female) 2014' which is available at   ' http://nhsrcindia.org/category -detail/policy -and- guidelines/ODY= '

ASHA is a community level voluntary health worker, who is trained and supported to play a set of healthcare support roles in her community. The roles and responsibilities of ASHA as per the ASHA Guidelines released by the GoI are at Annexure - II.

Contd……..

(d): ASHAs are envisaged as Volunta ry Health activists who received only task/activity based incentives and no deductions are made at national level.

The incentives to ASHAs finalized at the national level are regularly reviewed b Government and activities for which ASHAs would get incentives are expanded from time to time.  In  2013 , ASHA  incentiveswere enhanced  for  many  activities  and  new  incentives  for routine and recurring activities were introduced to ensure that ASHAs get at least Rs 10 -per month. Thereafter, the Mission Ste ering Group of NHM approved incentives for ASHAs at the rate of Rs.100 for notification if thesuspect referred is diagnosed to be T B patient by MO/Lab in 2014, Rs  100/ - per  round  during  Indoor  Residual  Spray  i.e.  Rs  200  in  total  for  two  rou Indoor Res idual Spray ,in 2015 and Rs. 150/case for escorting or facilitating beneficiary t health facility for the Post Abortion IUCD insertion ,in 2017.

Many States are also paying fixed monthly honorarium out of their State Budget. L ofState specific ASHA incentives/ fixed honorarium are at Annexure - III.

## Annexure - I

| SHORTFALL IN SUB -CENTRES AS PER 2011 POPULATION IN INDIA (As on 31st March, 2017)   | SHORTFALL IN SUB -CENTRES AS PER 2011 POPULATION IN INDIA (As on 31st March, 2017)   | SHORTFALL IN SUB -CENTRES AS PER 2011 POPULATION IN INDIA (As on 31st March, 2017)   | SHORTFALL IN SUB -CENTRES AS PER 2011 POPULATION IN INDIA (As on 31st March, 2017)   | SHORTFALL IN SUB -CENTRES AS PER 2011 POPULATION IN INDIA (As on 31st March, 2017)   | SHORTFALL IN SUB -CENTRES AS PER 2011 POPULATION IN INDIA (As on 31st March, 2017)   | SHORTFALL IN SUB -CENTRES AS PER 2011 POPULATION IN INDIA (As on 31st March, 2017)   | SHORTFALL IN SUB -CENTRES AS PER 2011 POPULATION IN INDIA (As on 31st March, 2017)   |
|--------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------|
| S.No.                                                                                | State/ UT                                                                            | Total Population in Rural Areas                                                      | Tribal Population in Rural Areas                                                     | Sub Centres                                                                          | Sub Centres                                                                          | Sub Centres                                                                          | Sub Centres                                                                          |
| S.No.                                                                                | State/ UT                                                                            | Total Population in Rural Areas                                                      | Tribal Population in Rural Areas                                                     | Required                                                                             | In Position                                                                          | Shortfall                                                                            | % Shortfall                                                                          |
| 1                                                                                    | Andhra Pradesh                                                                       | 34776389                                                                             | 2293102                                                                              | 7261                                                                                 | 7458                                                                                 | *                                                                                    | *                                                                                    |
| 2                                                                                    | Arunachal Pradesh                                                                    | 1066358                                                                              | 789846                                                                               | 318                                                                                  | 312                                                                                  | 6                                                                                    | 2                                                                                    |
| 3                                                                                    | Assam                                                                                | 26807034                                                                             | 3665405                                                                              | 5850                                                                                 | 4621                                                                                 | 1229                                                                                 | 21                                                                                   |
| 4                                                                                    | Bihar                                                                                | 92341436                                                                             | 1270851                                                                              | 18637                                                                                | 9949                                                                                 | 8688                                                                                 | 47                                                                                   |
| 5                                                                                    | Chhattisgarh                                                                         | 19607961                                                                             | 7231082                                                                              | 4885                                                                                 | 5186                                                                                 | *                                                                                    | *                                                                                    |
| 6                                                                                    | Goa                                                                                  | 551731                                                                               | 87639                                                                                | 122                                                                                  | 214                                                                                  | *                                                                                    | *                                                                                    |
| 7                                                                                    | Gujarat                                                                              | 34694609                                                                             | 8021848                                                                              | 8008                                                                                 | 9082                                                                                 | *                                                                                    | *                                                                                    |
| 8                                                                                    | Haryana                                                                              | 16509359                                                                             | 0                                                                                    | 3301                                                                                 | 2589                                                                                 | 712                                                                                  | 22                                                                                   |
| 9                                                                                    | Himachal Pradesh                                                                     | 6176050                                                                              | 374392                                                                               | 1285                                                                                 | 2083                                                                                 | *                                                                                    | *                                                                                    |
| 10                                                                                   | Jammu & Kashmir                                                                      | 9108060                                                                              | 1406833                                                                              | 2009                                                                                 | 2967                                                                                 | *                                                                                    | *                                                                                    |
| 11                                                                                   | Jharkhand                                                                            | 25055073                                                                             | 7868150                                                                              | 6060                                                                                 | 3848                                                                                 | 2212                                                                                 | 37                                                                                   |
| 12                                                                                   | Karnataka                                                                            | 37469335                                                                             | 3429791                                                                              | 7951                                                                                 | 9381                                                                                 | *                                                                                    | *                                                                                    |
| 13                                                                                   | Kerala                                                                               | 17471135                                                                             | 433092                                                                               | 3551                                                                                 | 5380                                                                                 | *                                                                                    | *                                                                                    |
| 14                                                                                   | Madhya Pradesh                                                                       | 52557404                                                                             | 14276874                                                                             | 12415                                                                                | 9192                                                                                 | 3223                                                                                 | 26                                                                                   |
| 15                                                                                   | Maharashtra                                                                          | 61556074                                                                             | 9006077                                                                              | 13512                                                                                | 10580                                                                                | 2932                                                                                 | 22                                                                                   |
| 16                                                                                   | Manipur                                                                              | 2021640                                                                              | 791126                                                                               | 509                                                                                  | 421                                                                                  | 88                                                                                   | 17                                                                                   |
| 17                                                                                   | Meghalaya                                                                            | 2371439                                                                              | 2136891                                                                              | 759                                                                                  | 436                                                                                  | 323                                                                                  | 43                                                                                   |
| 18                                                                                   | Mizoram                                                                              | 525435                                                                               | 507467                                                                               | 172                                                                                  | 370                                                                                  | *                                                                                    | *                                                                                    |
| 19                                                                                   | Nagaland                                                                             | 1407536                                                                              | 1306838                                                                              | 455                                                                                  | 396                                                                                  | 59                                                                                   | 13                                                                                   |
| 20                                                                                   | Odisha                                                                               | 34970562                                                                             | 8994967                                                                              | 8193                                                                                 | 6688                                                                                 | 1505                                                                                 | 18                                                                                   |
| 21                                                                                   | Punjab                                                                               | 17344192                                                                             | 0                                                                                    | 3468                                                                                 | 2950                                                                                 | 518                                                                                  | 15                                                                                   |
| 22                                                                                   | Rajasthan                                                                            | 51500352                                                                             | 8693123                                                                              | 11459                                                                                | 14406                                                                                | *                                                                                    | *                                                                                    |
| 23                                                                                   | Sikkim                                                                               | 456999                                                                               | 167146                                                                               | 113                                                                                  | 147                                                                                  | *                                                                                    | *                                                                                    |
| 24                                                                                   | Tamil Nadu                                                                           | 37229590                                                                             | 660280                                                                               | 7533                                                                                 | 8712                                                                                 | *                                                                                    | *                                                                                    |
| 25                                                                                   | Telangana                                                                            | 21585313                                                                             | 2939027                                                                              | 4708                                                                                 | 4797                                                                                 | *                                                                                    | *                                                                                    |
| 26                                                                                   | Tripura                                                                              | 2712464                                                                              | 1117566                                                                              | 691                                                                                  | 987                                                                                  | *                                                                                    | *                                                                                    |
| 27                                                                                   | Uttarakhand                                                                          | 7036954                                                                              | 264819                                                                               | 1442                                                                                 | 1847                                                                                 | *                                                                                    | *                                                                                    |
| 28                                                                                   | Uttar Pradesh                                                                        | 155317278                                                                            | 1031076                                                                              | 31200                                                                                | 20521                                                                                | 10679                                                                                | 34                                                                                   |
| 29                                                                                   | West Bengal                                                                          | 62183113                                                                             | 4855115                                                                              | 13083                                                                                | 10369                                                                                | 2714                                                                                 | 21                                                                                   |
| 30                                                                                   | A & N Islands                                                                        | 237093                                                                               | 26715                                                                                | 50                                                                                   | 123                                                                                  | *                                                                                    | *                                                                                    |
| 31                                                                                   | Chandigarh                                                                           | 28991                                                                                | 0                                                                                    | 5                                                                                    | 17                                                                                   | *                                                                                    | *                                                                                    |
| 32                                                                                   | D & N Haveli                                                                         | 183114                                                                               | 150944                                                                               | 56                                                                                   | 71                                                                                   | - 15                                                                                 | - 27                                                                                 |
| 33                                                                                   | Daman & Diu                                                                          | 60396                                                                                | 7617                                                                                 | 13                                                                                   | 26                                                                                   | *                                                                                    | *                                                                                    |
| 34                                                                                   | Delhi                                                                                | 419042                                                                               | 0                                                                                    | 83                                                                                   | 10                                                                                   | 73                                                                                   | 88                                                                                   |
| 35                                                                                   | Lakshadweep                                                                          |                                                                                      | 13463                                                                                | 4                                                                                    | 14                                                                                   | *                                                                                    | *                                                                                    |
| 36                                                                                   |                                                                                      | 14141                                                                                |                                                                                      |                                                                                      |                                                                                      |                                                                                      |                                                                                      |
|                                                                                      | Puducherry All India/ Total                                                          | 395200 833748852                                                                     | 0 93819162                                                                           | 79 179240                                                                            | 81 156231                                                                            | * 34946                                                                              | * 19                                                                                 |

Notes: The requirement is calculated using the prescribed norms on the basis of rural population from Census

2011.  All India shortfall is derived by adding state -wise figures of shortfall ignoring the existing surplus in some of the states.

*: Surplus

## Roles and Responsibilities of an ASHA

The roles and responsibilities of an ASHA include the functions of a healthcare facili service  provider  and  a  health  activist.  Broadly  her  functions  involve  providing  prev promotive  and  basi c  curative  care  in  a  role  complementary  to  other  health  functionari educating and mobilizing communities particularly those belonging to marginaliz communities,  for  adopting  behaviours  related  to  better  health  and  create  awareness  on determinan ts, enhancing better utilization of health services; participation in health c and enabling people to claim health entitlements.

Her roles and responsibilities would be as follows:

- ASHA will take steps to create awareness and provide information to the community determinants of health such as nutrition, basic sanitation and hygienic practices, living and working conditions, information on existing health services and the n eed for timely use of health services.
- She will counsel women and families on birth preparedness, importance of safe deliv breastfeeding and complementary feeding, immunization, contraception and preventio of  common  infections  including  Reproductive Tract  Infection/Sexually  Transmitted Infection (RTIs/STIs) and care of the young child.
- ASHAwillmobilizethecommunityandfacilitatepeople'saccesstohealthandhealthrelated services available at the village/sub -centre/primary health centres, such as Immuniza tion, Ante Natal Check - up  (ANC),  Post  Natal  Check - up  (PNC),  ICDS,  sanitation  and  other services being provided by the government.
- She will work with the Village Health, Sanitation and Nutrition Committee to devel comprehensive village health plan, an d promote convergent action by the committee on social determinants of health. In support with VHSNC, ASHAs will assist and mobili the community for action against gender based violence.
- She  will  arrange  escort/accompany  pregnant  women  &  children  requi ring  treatment/ admission to the nearest pre -identified health facility i.e. Primary Centre/Community Health Centre/First Referral Unit (PHC/CHC/FRU).

Health

- ASHA will provide community level curative care for minor ailments such as diarrho fevers, c are for the normal and sick newborn, childhood illnesses and first aid. She be  a  provider  of  Directly  Observed  Treatment  Short - course  (DOTS)  under  Revised National  Tuberculosis  Control  Programme.  She  will  also  act  as  a  depot  holder essential  healt h  products  appropriate  to  local  community  needs.  A  Drug  Kit  will  be provided to each ASHA. Contents of the kit will be based on the recommendations of expert/technical advisory group set up by the Government of India. These will be up from time to time, States can add to the list as appropriate.
- TheASHA'sroleasacareprovidercanbeenhancedbasedonstateneeds.Statescanexplore the possibility of graded training to the ASHA to provide palliative care, screening f -communicable diseases, childhood d isability, mental health, geriatric care and others.
- TheASHAwillprovideinformationonaboutthebirthsanddeathsinhervillageandanyunusual health problems/disease outbreaks in the community to the Sub - Centres/Primary Health

Centre.  She  will  promote  constructio n  of  household  toilets  under  Total  Sanitation Campaign.

The ASHA will fulfill her role through five activities:

1. Home Visits: For up to two hours every day, for at least four or five days a wee ASHA  should  visit  the  families  living  in  her  allotted area,  with  first  priority  being accorded to marginalized families. Home visits are intended for health promotion preventive care. They are important not only for the services that ASHA provides reproductive,  maternal,  newborn  and  child  health  inte rventions,  but  also  for  non -communicable diseases, disability, and mental health. The ASHA should prioritize hom where  there  is  a  pregnant  woman,  newborn,  child  below  two  years  of  age,  or malnourished child. Home visits to these households should take place at least once in a month. Where there is a new born in the house, a series of six visits or more be essential.
2. Attending the Village Health and Nutrition Day (VHND): The ASHA should promote attendance  at  the  monthly  Village  Health  and  Nutriti on  Day  by  those  who  need Aganwadi or Auxiliary Nurse Midwife (ANM) services and help with counselling, healt education and access to services.
3. Visits to the health facility: This usually involves accompanying a pregnant woman, child,  or  some  member of  the  community  needing  facility  based  care.  The  ASHA  is expected to attend the monthly review meeting held at the PHC.
4. Holding village level meeting: As a member or member secretary of the Village Heal Sanitation and Nutrition Committee (VHSNC), th e ASHA is expected to help convene the  monthly  meeting  of  the  VHSNC  and  provide  leadership  and  guidance  to  its functioning. These meetings are supplemented with additional habitation level meet if necessary, for providing health education to the commun ity.
5. Maintain records: Maintaining records which help her in organizing her work and h her to plan better for the health of the people.

## Other State Specific Incentives for ASHAs

1. Chhattisgarh gives 50% of matching amount of the incentives over and above the incentives earned by an ASHA as a top up on an annual basis
2. Haryana (Rs. 1000/month)
3. Kerala (Rs.1500/month, Rajasthan (Rs. 1600/month through ICDS),
4. Karnataka (Rs. 3500/month -recently introduced replacing the top up in centive)
5. Sikkim (Rs. 3000/month)
6. Meghalaya and Tripura provide 100%matching amount of the incentives over and above the incentives earned by an ASHA as a top up on an annual basis.
7. West Bengal (Rs. 2000/month).
8. Recently  states  of  Gujarat,  Telangana  and Uttrakhand  have  also  introduced incentives from state funds but modalities of payment are not available.

## Annexure - III