Leveraging iFIX To Enable Timely Payments To Frontline Health Workers

1. Objective

The purpose of this document is to explore how improving information flow through an integrated Fiscal Exchange (iFIX) can address some of the challenges in the health sector. To illustrate the applicability of iFIX for the health sector, we have chosen delayed payments to Accredited Social Health Activist workers, also referred to as ASHAs, as a use case.

This page covers -

• A generalised view of the current payment process for ASHAs, however, there can be variations across state governments

• The commonly sighted challenges and issues for delays in payments

• By improving information exchange through iFIX, how some of the underlying pivotal problems can be addressed, namely -

• The flow of information and visibility across the value chain for various actors

• The cost of coordination between departments and administrative levels

While there are many other issues that have a role to play in bringing about systemic change, including changes to policy or governance, the scope of this document is limited to the above-mentioned areas.

The intended audience for this document is anyone who wants to understand how payments to front-line workers can be streamlined, using a fiscal exchange platform.

2. Context

ASHA workers are community health (women) volunteers who are primarily responsible for making sure women and children have access to better and timely healthcare. Though there is a wider prevalence of ASHAs in rural areas, they are engaged in semi-urban, peri-urban and urban areas as well, and this varies from state to state. Generally, ASHAs fall within the 25-45 year age group, are literate and educated till the 8th grade. They have a high level of familiarity with the local population and they are expected to reach out and influence the community on health interventions. One ASHA is designated to serve an area of approximately 1000 people. As per National Health Mission (NHM) statistics of 2019, there are 10.4 lakh ASHAs in India - covering rural, urban and semi-urban areas

To carry out their activities they are effectively supported by a few senior ASHAs (ASHA facilitators) in a few states. For every 5-10 ASHAs, a facilitator is assigned to help them onboard and train on their day-to-day activities. An ASHA facilitator may be assigned additional activities to an ASHA (in some states) and may also earn higher incentives. The payment process however is similar to an ASHA worker. There is also an Auxiliary nurse midwife (ANM) available per 10,000-12,000 people, who is a trained clinical nurse and is a salaried professional with regular pay and benefits. ASHAs interact with other health administration roles such as block officers (ASHA activity approvals), Medical officers in charge (MoiC) at facilities.

The diagram below tries to sum up the different individuals and committees that an ASHA interacts with at different levels.

3. Role Of ASHAs & Challenges

ASHA workers are responsible for a wide range of frontline health activities in their allocated area. NHM has outlined more than 60 activities, across preventive and curative care, that can be performed by an ASHA. States also additionally outline activities for ASHAs based on the state’s health priorities and disease burden from time to time (for e.g. Bihar has outlined 96 activities).

They are however roped in for ad-hoc activities as well, as and when the state’s health system needs their support, which goes unaccounted or unrecognised, such as COVID surveys, contact tracing etc.

It is important to note that the role of the ASHA has evolved over time, it started as a volunteering activity, which does not interfere with their normal livelihood. Over time it has become a full-fledged >30-40 hours work week with more frontline activities being added to their role but very little or no change in how and how much they will be paid.

ASHAs are a very important link in the public health delivery value chain, who unfortunately have to deal with several systemic and social challenges as part of their work including but not limited to (no order of priority):

1. Difficult working conditions - Field work continues through the soaring summer temperatures, monsoon flooding and harsh winters. Heavy boxes of vaccinations (e.g. polio vaccinations), registers and ASHA diaries are required to be carried over an area ranging anywhere between 2-5 km on foot. Basic workplace necessities such as clean washrooms, drinking water, and protective gear during the pandemic are missing. Interfacing with health conditions coupled with complex social issues sometimes puts them at risk in local communities and adds to their hardship.

2. Low earning potential with meagre social security benefits - The monthly fixed component is around INR 4000 and based on activities allocated, an ASHA worker can earn a variable pay between INR 2000-8000 (i.e. <~150 USD). Other benefits such as travel allowances (only for training) and accidental insurance are provided but the value is low.

3. Uncertain and delayed payments - The delays in payments impact the livelihoods of the ASHAs and the last-mile delivery of healthcare services, maternal healthcare, immunisation programmes etc. There have been multiple instances of ASHA workers going on strike to highlight the extent of delay in payments.

4. Understanding Asha Payment Process

State health departments receive their funding from the National Health Mission (NHM) which is the central contribution of 60% and from the state budget 40% (except in North-Eastern states). This forms the health budget of the state and is the primary source of funds for the ASHA workers. They are also funded by other programmes and departments such as the National vector-borne disease board, the ministry of drinking water and sanitation, etc. (Refer Appendix 2)

As ASHA workers are contracted as volunteers by the health departments of state governments they do not come under the Minimum Wage Act, there is no standardisation in their remuneration and no minimum wage entitlement. The payment structure and incentives are decided by the state health departments and can vary from state to state. The payment structure to ASHAs are predominantly based on:

• Variable performance incentives - the incentives are decided depending on the type of task and the activity performed - community or institutional, state or centre specific, programme, etc.

• Fixed allowance - ASHAs also receive a fixed monthly amount over and above the variable task-based incentives, based on the recent centre and state directives.

Process Of Disbursing Asha Payments

The process entails 5 key steps, generally performed at the end of every month:

1. Submission of claim forms with relevant proofs

2. Review - documents, proofs, field assessments

3. Collation of payment advice and associating them with respective Financial Management Reporting (FMR) codes

4. Approval by multiple administrative levels

5. Disbursement of funds via Direct Benefits Transfer (DBT) to ASHA bank account

The following diagram illustrates an indicative process for ASHA payments that is followed by most of the states in India. It is important to note there are no standard guidelines on the approval process for ASHA payments and hence this varies from state to state.

Based on the information gathered during interviews, we realized that the delays in the verification, approvals and reconciliation of information happen primarily because of the following reasons from an information synthesis perspective (not an exhaustive list):

1. Collation of information from multiple sources/formats/systems/stakeholders

2. The Sequential flow of information from one level to another/department to another

3. Correlating service information with the right fiscal standards for further processing

Current Process Challenges

Lack of digital information on last-mile service delivery

Although multiple digitisation efforts have been made to digitise service delivery information with the implementation of ANMOL, (RCH), ABDM and multiple HMISs, there are very few efforts being made to digitize the information being collected at the last mile by the ASHAs.

Unfortunately, these efforts existed in pilots and could not be scaled up across the country. Multiple reasons such as low adoption, low digital literacy of the ASHAs, lack of funds, lack of intention from the state to scale up and/or ineffective program management, amongst others accounted for it.

The flow of information is slow, sequential and limited.

Planning and fund utilisation

State leads need to submit fund utilisation certificates to demand for more funds from the centre. Program managers (block, district, state) need to monitor the timelines and comply with the guidelines related to the submission of fund utilization certificates and PIPs.

Funds are released from the centre only after 80% of the utilization of previous funds. So if utilisation certificates are not produced on time and even if 25% of funds are remaining, the state cannot request more funds resulting in not enough money being left to pay to the ASHAs.

Execution - delays in approvals

The flow of information for the monthly ASHA payment process goes through multiple approvals - each level requiring a certain amount of information to process the same, with limited bandwidth. But this information flows sequentially across levels and hence is slow, non-standardised and limited. This leads to delays in approvals.

The problem of plenty: multiple systems and formats creating information silos and disaggregated information sets

Multiple systems being used for exchanging and managing:

1. Service delivery information - facility level HMISs, RCH portal, digital record of activities in ASHA-soft, ASHWIN (Bihar specific), approval systems, claim forms supported with physical ASHA diaries, multiple registers, etc.

2. Fiscal information systems - IFMIS, PFMS and other systems being used to track fund disbursement, payments, approvals, etc.

The information does not flow from one system to another making the process of collation and review even more difficult.

Digital systems also suffer from duplicity issues (issues reported in ASHA-soft), repudiation, redundancy of information and inconsistency in formats and standards.

This ultimately increases the cost of coordination with ASHAs paying that cost with delays in payments. Few states have implemented multiple digital or manual systems to perform one or more components of the process.

5. How iFIX Resolves These Issues

What is iFIX?

Integrated Fiscal information exchange platform (iFIX) aims to provide real-time information on the financial health at the district or the state level in terms of expenditure, revenue as well as available funds. It aims to establish a connection between financial expenditure, physical progress and outcomes with the objective of identifying the returns obtained from public expenditure. The solution provides transparency and improves accountability while ensuring real-time access to the financial health of the government.

Mapping Current Process Challenges Vis-a-vis Pivotal Problems

An overall understanding of the ASHA payment approval process and the challenges actors face can be drawn from the information below. We have taken an attempt to map the causes with the pivotal problems highlighted above.

Reimagining ASHA Payment Process With iFIX

iFIX enables real-time visibility into fund flows

When multiple systems begin posting fiscal events to IFIX, the most immediate benefit is that any authorised viewer can see the status of funds within these multiple systems. Since this information is included in the fiscal events, viewers should be able to see:

Every fiscal event can be reported using a CoA or FMR code related to the activity and hence bringing down the cost of coordination between different levels, systems, and departments.

iFIX enables the linkage of service delivery information with fiscal events

The pivotal problem of disjoint systems and siloed information can be solved using iFIX where service events can be configured to trigger fiscal events which feed data into the platform. Process and policy changes might be required to assess which service events.

1. Can automatically trigger fiscal events

2. Need approval before triggering fiscal events

[Refer Appendix 5 for more details]

An attempt to facilitate event mapping and data attributes for a couple of activities that an ASHA does is outlined below for reference and as an example:

1) Service events which require approval (captured outside iFIX but can trigger fiscal events)

Completion of activity

Verification of activity (captured outside iFIX)

Associated Fiscal Event Information

Creation of bill

Payment

2) Service events which do not require an approval

Completion of activity with a digital record (captured outside iFIX but can trigger fiscal events)

Associated Fiscal Event Information

Creation of bill

Payment

iFIX enabling interoperability across systems

Standard registries

The systems mentioned during the course of the document, have a lot of master data which is specific to a state and not standardised.

Using iFIX and open source principles, the same information can be saved into standard registries for enabling standardisation and interoperability

A few sample registries with indicative data attributes that need to be created per state implementation have been outlined in Appendix 3.

These are not comprehensive and might vary from state to state.

Standardised transactional fiscal information

Each system can post fiscal events into iFIX based on triggers developed or identified.

For e.g.

1. As soon as ASHA creates an activity, a fiscal event can be triggered either from a system or on a claim form submission.

2. This fiscal event can initiate notifications/ visibility into upcoming events such as approvals, and disbursements which impact fund flows.

iFIX enables better decision-making for stakeholders

For each of the stakeholders, with iFIX, they should be able to view (indicative and not comprehensive):

ASHAs:

Claim information and status -

• Status of claim forms submitted for the previous and current months

• Amount of each claim form

• Approver information and current status of approvals

Approvers:

• Asha-wise approval status

• Total amount, # of pending claims

• Status of claim forms submitted for the previous and current months

• Amount of each claim form

• Approver information and current status of approvals

Administrators:

• The total amount of funds available to ASHAs

• Whether the funds have been

  • Spent - if spent, under which FMR code or stream

  • Or Need to be budgeted/estimated for

  • The entire chain of events and officials involved with planning, estimating, approving, and expending these funds, including those who recorded or approved any interim milestones

• Approval/verification and audit status of any given expenditure

The availability of this information immediately addresses some of the challenges observed currently for administrators. For e.g. generation of the utilisation certificate (UC). It can be transformed into much more flexible and specific controls, as both expenditure and project status are visible.

Constraints / Challenges / Assumptions

People

Digital literacy at the grassroots - Although internet penetration in India is one of the highest in the world when it comes to operating systems effectively at the village level, it is quite low. This affects the data entry, quality and hence decision making.

ASHAs are not digitally savvy yet to be able to adopt a mobile application without multiple rounds of training and refreshers. Hence it becomes imperative to have strong program management in place with effective change management policies.

Fiscal literacy at the grassroots level - Correlating the right fiscal information with service information is imperative for this system to work and hence it is important to impart basic knowledge about FMR codes, fiscal transactions, etc to all stakeholders involved.

Process / Policy / Governance

Standardisation of the approval process across states - Currently, the process varies from state to state and hence one single digital platform is not able to cater to the needs of every state. Due to this, either each state has their own siloed system or the pilots being performed are not scalable across the country.

Policy changes are required to identify if

• An approval process is required

  • If required, is it necessary for all ASHA activities [See Appendix 5]

  • If not required, then how do we build validation and verification using technology (e.g. GPS to map addresses of beneficiaries, photographs to share proof of service delivery, etc.)

• Pilferage in the process in terms of Out-Of-Pocket (OOP) payments for data entries, approvals, etc. might exist and cannot be accounted for.

• Timely release of funds from the centre or the state to make the payments

Technology

Availability of service information in a standardised digital form - Since most of the tasks being performed by ASHAs today are recorded on registers, diaries, lists, and physical survey forms on a day-to-day basis, it becomes difficult to collate and share them in a digital format. iFIX cannot solve this as highlighted earlier.

Hence inputs as highlighted in this Section earlier need to be captured using digital systems (utilities, chron jobs, applications etc.). Efforts are required to build digital systems to record this information with complete validation. For e.g. a mobile app with certain capabilities like

1. Offline online sync of service delivery data

2. GPS tracking to accurately record point-to-point service delivery information

3. Ability to capture proofs of service delivery in the form of photographs etc.

6. Conclusion

The fundamental role of iFIX would be to enable the planning and estimation of funds for health programmes and schemes using data available from the relevant registries and systems. Availability of this fiscal information across the entire budget cycle could then also facilitate better, faster and more accurate audits. These efforts would, in the long term, solve the unintended consequences of the delayed payments made to ASHAs.

Ensuring timely payments to frontline health workers and ASHAs is closely aligned with ensuring better public health outcomes. Improving public health outcomes themselves are dependent on a large number of decisions, a lot of them linked to trustworthy information about the flow of funds and their efficient movement within the system.

It is however important to be emphasised that the ability of iFIX to enable information exchange for timely payments to ASHAs depends on the ability of the government department to proactively engage in

1. Helping build utilities to convert physical data into digital forms that can be fed into iFIX adaptor

2. Enabling and facilitating information exchange with existing state and central systems

3. Maintaining and utilising the registries.

Extensibility of the use case

For front-line workers

The proposed implementation of a fiscal exchange layer between service delivery and financial systems can be extended to resolve the following problems faced by the 2 billion global front-line workers.

1. The problem of delayed and ad hoc payments

2. Implement performance-based payments to resolve low wages

For decision-makers

The fiscal sustainability dashboards can enable faster decision-making and effective health resource tracking for administrators in times of crises like pandemics, catastrophes and outbreaks.

For other domains

Associating payments with performance and disbursing payments for contractual workers has been a cause of concern across different domains (including public works, education, etc.). This use case can be extended to any domain where multiple systems are involved, information flows sequentially and service delivery data rests outside the fiscal systems.

7. Appendix

Appendix 1

Appendix 2

No single budget head for ASHA incentives

As each incentive is tied to a different activity, they are drawn from various financing pools of NHM or from funds allocated for different programmes or societies. In the planning process, incentive payout for ASHAs is not considered separately; rather it follows the planning and budgeting considerations of multiple programmes within or outside NHM.

Refer the table below for illustrations:

On top of this, there might be state-specific activities linked to different pools or budget heads. For e.g. in Bihar where the disease burden of Japanese Encephalitis is quite high, there are at least 2 activities related to JE awareness, evidence collection, drug adherence and spread management.

Source: ASHWIN activity list

Appendix 3

Attributes highlighted in orange are primary keys or identifiers, while attributes that are bolded are foreign keys or can be used to map to other registries.

ASHA Registry

Similar registries can be created for ANM, Block officers (BCM, BCH,), district officers, and state nodal officers required for approvals.

Block Registry

Village Registry

*More than 1 village can be tagged to an ASHA and more than 1 ASHAs can be tagged to a single village depending on the population size of the village.

Health Facility Registry

Registry of FMR Codes

Registry of ASHA registers

Registry of ASHA activities

A sample transaction of any activity can consist of the following attributes fetched using the registries outlined above:

Appendix 4

1. Digital record of ASHA activities - There are several systems like Techo+, ASHA soft which help in keeping a record of activities.

2. Digital proof submission and Approval flow - For e.g. ASHWIN in Bihar, ASHA incentive application in UP, Swasthya Seva dapoon in Assam

3. Smart / Digital payments - In most of the states, payments are made via DBT using PFMS or state/central FMS by sending the following information:

   • Amount

   • Verified bank account details of the ASHAs (a/c no, IFSC code, etc.)

   • ASHA details (name, etc.)

4. Other adjacent systems - There are multiple adjacent systems (both digital and physical) which contain the following:

   • Patient health record - e.g. HMIS (e-Hospital, e-Sushrut), Labour room registers, ABDM integrated systems

   • Beneficiary information - e.g. RCH registers, Lists, surveys, PMJAY etc

   • Service delivery information - e.g. RCH portal, PMJAY (claims)

   • Bank systems

   • Identity systems - AADHAR, ABHA account id, PMJAY Id, etc

Appendix 5

Suggested process improvements

An analysis is required to understand whether all activities performed by the ASHAs need to go through the approval process for availing the fiscal benefits.

We have taken an attempt to classify activities based on whether they can be categorised as:

1) Traceable i.e. need no approval

For e.g. creation and updation of an eligible couple list in the village

These activities might require proof in the form of

• Photographs

• Automatically generated records

• GPS-enabled location capture for point-to-point delivery of service

2) Non-traceable i.e. require some form of approval

For e.g. distribution of iron folic tablets to pregnant women or the administration of polio drops from door to door.

These activities will require validation and review by ANMs and Block Officers either in the form of:

• Digital proofs - photographs, digital lists, etc OR

• Manual - sample review, review of any paper-based data collection

Appendix 6

Based on interviews with multiple partners in healthcare service delivery, ASHAs, etc. an indicative, detailed process flow has been drafted here. This varies from state to state hence it is indicative in nature.

Interviews / References

1. Sumit Pandey, State lead, Gujarat (RISE), JHPIEGO

2. <> Piramal Foundation

3. ASHAs in Bihar (Mamta, Vinita Devi)

4. NHM site - central and a few state-specific sites

5. Multiple news articles, blogs research papers, NHSRC reports, etc. as highlighted in respective pages in the form of footnotes and hyperlinks

Questions

1. PFMS - health module - FMR code

2. Create (accountant) - submit - approval (MoiC / block) - advice 100 Ashas - total payment

3. PFMS - Vendor management - receiving - block officer/approval authority has access to viewing? - manual book of accounts??

4. PFMS - is it being used for centrally sponsored schemes/state sponsored schemes?

5. Utilisation certificate periodicity?

6. Scheme A / Scheme B - payment to ASHAs partial?

Do we wait for funds on all line items to be disbursed?

8. Abbreviations