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 Table of Contents  
Year : 2020  |  Volume : 64  |  Issue : 1  |  Page : 66-71  

Home-based newborn care voucher initiative in Assam: An evaluation

1 Chief, UNICEF, Guwahati, Assam, India
2 Associate Professor, Department of Community Medicine, Tezpur Medical College, Tezpur, Assam, India
3 Health Officer, UNICEF, Guwahati, Assam, India
4 Statistician, MCH Cell, AMC, Dibrugarh, Assam, India
5 Assistant Professor, Department of Community Medicine, Assam Medical College, Dibrugarh, Assam, India

Date of Submission21-Apr-2019
Date of Decision11-Jun-2019
Date of Acceptance15-Feb-2020
Date of Web Publication16-Mar-2020

Correspondence Address:
Tulika Goswami Mahanta
Satsang Vihar Road, Jyotinagar, Dibrugarh - 786 001, Assam, India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.IJPH_188_19

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Background: An innovative home-based newborn care (HBNC) voucher system has been introduced in Assam to improve home visits of accredited social health activists (ASHAs), make them more accountable, and empower the community. Objective: This study aimed to evaluate the effectiveness of HBNC voucher initiative in Assam. Methods: A mixed methodology study was conducted in 2018 including 4 districts of Assam. A quantitative study was done among a sample of 836 lactating mothers by interviewing them through house-to-house visits. A qualitative study was done by in-depth interview of various health-care service providers. Results: Of 836 lactating mothers, 65% received HBNC voucher; 45.6% received at the time of discharge, and 5.3% during antenatal care. The purpose of HBNC vouchers as a tool of validating ASHAs' home visits was explained to only 14.5% of lactating mothers. Examination of newborn (44.6%), counseling on breastfeeding (57.1%), counseling on care of baby (39.2%), and counseling on immunization (49.2%) were the services commonly provided by ASHA during HBNC visits. Voucher system improved incentive payment system, but uninterrupted supply was a problem area as stated by ASHAs. Auxiliary nurse midwives and ASHA supervisors told that voucher system had improved ASHA home visits, payment system, and increased identification of danger signs of newborns. Conclusions: HBNC voucher system as an innovative approach was found to be effective. Coverage of services varied among different districts. Uninterrupted supply of the vouchers, periodic resensitization of health workers on its use, and increasing awareness among the community is needed to be sustained.

Keywords: Assam, health innovation, home-based newborn care, voucher system

How to cite this article:
Rane TM, Mahanta TG, Ryavanki SP, Gogoi B, Boruah M. Home-based newborn care voucher initiative in Assam: An evaluation. Indian J Public Health 2020;64:66-71

How to cite this URL:
Rane TM, Mahanta TG, Ryavanki SP, Gogoi B, Boruah M. Home-based newborn care voucher initiative in Assam: An evaluation. Indian J Public Health [serial online] 2020 [cited 2023 Feb 8];64:66-71. Available from:

   Introduction Top

Globally, 46% of children died during neonatal period, and if this trend continues, by 2030, 50% of them will die as newborns.[1],[2],[3],[4] Survival, optimal growth, development, and prevention of infections are most critical in this period. Birth asphyxia, sepsis, pneumonia, and preterm being the leading causes of mortality in Assam are also largely preventable.[5],[6] Newborn deaths at home due to limited community interventions were common. In this context, the state of Assam adopted guidelines on home-based newborn care (HBNC) issued by the Ministry of Health and Family Welfare, Government of India, to ensure that all newborns are provided care at home by accredited social health activist (ASHA) through a defined number of visits (6 numbers) at defined interval following birth, for which the worker is paid financial incentives. The HBNC program was rolled out in all districts of Assam.

However, HBNC program was not devoid of implementation challenges. Although training of ASHAs on HBNC was 97%, retention of skills was a challenge. Discrepancies existed between number of newborns visited and HBNC incentives paid. Monitoring/supportive supervision was not well defined to validate home visits. To address these gaps, the UNICEF piloted the HBNC voucher initiative in a high priority district of Assam. In this system, mothers who delivered were given a set of six HBNC vouchers. When an ASHA goes to the mother's house for HBNC visits and examines the baby using the standard recording format, mothers/caregivers are supposed to hand over a voucher. For each visit, she receives one voucher from the mother. The ASHA can claim and receive the HBNC incentive only after all the six vouchers have been submitted along with a claim form validated by auxiliary nurse midwives (ANMs)/ASHA supervisors. This was a mechanism to make ASHAs more accountable and empower the community. The study of this voucher mechanism showed that the introduction of the vouchers in HBNC increased knowledge, awareness, and utilization of HBNC services and had the potential to strengthen the health system.[7] Voucher mechanism in HBNC was then scaled up by the Government of Assam to cover all districts. This study was undertaken to assess the effectiveness of HBNC voucher initiative in Assam.

   Materials and Methods Top

Study design and study subjects

A rapid assessment of HBNC voucher implementation, monitoring, and experience among beneficiaries (lactating mothers) and service providers was done between January and March 2018 through a mixed method study. Among the lactating mothers, a quantitative community-based cross-sectional study was done and qualitative assessment of service providers of those areas was done by in-depth interviews.

The study was done among lactating mothers who have completed 2 months postdelivery and whose child was below 1 year of age. Health-care providers of those areas were also included in the study, namely ASHAs, ASHA supervisors, and ANMs, for the qualitative part.

Study area and sampling

The minimum sample size for the cross-sectional study among the lactating mothers was calculated to be 800 in the following manner: considering knowledge among lactating mothers about services that should be provided by the ASHA as 67.7% with 7% relative precision and 95% confidence level, the required sample size was 374, and considering design effect of 2, sample size becomes 748, which was inflated to 800 keeping into consideration nonresponse and rounding up.[7]

The multistage random sampling design was adopted as follows:

In the first stage, four districts were selected from the state: (a) two from good-performing districts with regard to HBNC – district with over 80% coverage of HBNC and over 80% ASHAs trained in Round 1 and Round 3 of modules 6 and 7. Two selected districts were-Sivsagar and Sonitpur. (b) Two from poor-performing districts with regard to HBNC – district with <50% coverage of HBNC and over 80% of ASHAs trained in Round 1 of Module 6 and 7 and 50% trained in Round 3 of module 6 and 7. The selected districts were Jorhat and Dhubri.

In the second stage, in each selected district, two blocks were selected randomly, and in the next stage in each block, two-sector primary health centers (PHCs) were selected randomly. From each PHC area, two health subcenters (SC) were randomly selected. From each SC area, two villages were selected randomly for interview of lactating mothers.

Hence, in each district, eight SCs and 16 villages were included.

For the quantitative survey of lactating mothers, from each district, 200 lactating mothers were assessed by taking 13 from each of the 16 selected villages. For the qualitative assessment in each district, 8 ANMs, 8 ASHA facilitators, and 16 ASHAs were included for in-depth interview.

Tools and techniques – Data collection and analysis

Data were collected by interview of the lactating mothers by household visit using a structured questionnaire which was predesigned and pretested.

For qualitative study, in-depth interview (injecting drug user) of ASHAs, ASHA supervisors, and ANMs were done using a semi-structured pro forma.

Descriptive analysis was done for quantitative data. Chi-square test was used to see the difference in proportion between the “good-performing districts and poor-performing districts.”

Ethical issues

Ethical approval was obtained from the Institutional Ethical Committee; administrative permission was obtained from each district. Written informed consent was obtained from each participant.

   Results Top

Findings from the beneficiaries: Lactating mothers

A total of 836 eligible women participated in the study. Institutional delivery was significantly higher in good-performing districts (89.7%) compared to poor-performing districts (85.6%).

Overall, only 65% of lactating mothers received HBNC voucher (57.4% in good performing vs. 72.5% in poor performing, P = 0.000), indicating significantly higher supply in poor-performing districts. Ideally, mothers should receive the voucher during the time of discharge after delivery or in the antenatal period. However, only 45.6% received at the time of discharge and 5.3% during ANC. Timing of receipt of HBNC voucher was significantly different between the two groups of districts.

The purpose of HBNC vouchers as a tool of validating ASHAs' home visit was explained to 14.5% of the lactating mothers. In 70.4%, the purpose of HBNC vouchers was not explained.

Services provided by ASHA during HBNC visits were enquired from the lactating mothers. Services that were most commonly provided by ASHA included examination of newborn (44.6%), counseling on breastfeeding (57.1%), counseling on care of baby (39.2%), and counseling on immunization (49.2%). Essential newborn care was provided to overall 20.4% beneficiaries, and this was significantly higher in the good-performing districts (30.1%) compared to poor-performing districts (10.8%). Counseling mother on care of baby and immunization during HBNC visits was significantly higher in good-performing districts [Table 1].
Table 1: Comparison of different service provision between good- and poor-performing districts among beneficiaries of home-based newborn care system

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Implementation of home-based newborn care voucher: Findings from the perspective of accredited social health activists

During initiation of HBNC voucher system in districts, ASHAs were trained up on the workings of the voucher mechanism. Majority of the ASHAs (94%) were satisfied with the quality of such trainings.

52.1% of ASHAs said that they conducted community meeting in their villages on HBNC vouchers for increasing awareness. Different communication activities undertaken by ASHAs for HBNC voucher awareness were interpersonal communication (42%), posters (13%), and mothers meeting (15.9%). There was no significant difference in such awareness activities between the two groups of districts except the use of posters was higher in poor-performing districts.

Regarding benefits of the voucher system, it has improved the payment system, and they were getting regular payment of incentives for the home visits.

Regarding challenges faced in this system, 38% of ASHAs felt that there should be uninterrupted supply of the vouchers. 56.5% informed that they were getting a sufficient supply of HBNC vouchers, whereas 43.4% did not receive sufficient supply. Register was maintained for HBNC voucher in 76%, whereas in 18%, register was not maintained. The stock-out of HBNC voucher was present in 55% cases, which is between 3 and 6 months in majority of the cases (57%) [Table 2].
Table 2: Practice pattern and activities related to home-based newborn care among accredited social health activist in good- and poor-performing districts

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Implementation of home-based newborn care voucher: Findings from the perspective of supervisory-level service providers

ANM/ASHA supervisors informed that their role in HBNC voucher system was mainly supervisory. They have to cross-check claims of home visits of ASHAs for HBNC and then only sign the incentive claim forms of ASHAs. Before introduction of this voucher system, training was provided and 54.5% found these trainings satisfactory.

Majority (87%) said that they validate the HBNC visit done by ASHA, whereas 13% do not do that. Validation was done by home visit and cross-checking of visit in 81% of cases, whereas 10% told that they do home visit with ASHA.

Regarding the benefits of this system, majority informed that HBNC voucher system has improved HBNC visit of ASHA and that ASHA was now bound to go to the community for HBNC home visits and collect the voucher from mothers in order to get their incentive. Other benefits reported were improvement of the payment system of ASHA incentives for HBNC visits, increase in identification of danger sign, increase in the referral rate, and increase in outborn admission in sick newborn care unit [Table 3].
Table 3: Activities related to home-based newborn care among supervisory service providers (auxiliary nurse midwives and accredited social health activist supervisor) in good- and poor-performing districts

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   Discussion Top

HBNC vouchers were received by majority and in a timely manner, verified by supervisory-level workers, so the purpose as a tool for validation of ASHAs' home visit was found effective. Service provision by ASHA on various components of essential newborn care was found effective as informed by caregiver, i.e., lactating mothers, and it was significantly higher in good-performing districts. This system improved the incentive received by ASHA for home visits along with improvement of quality of services of ASHA visit. There was an increased identification of danger sign, timely referral. However, there was a need for having refreshers training of ASHA on essential newborn care and strengthened monitoring and supportive supervision mechanism for better delivery of HBNC services. Ideally, everyone should receive the voucher during the time of discharge or antenatal period. A previous study done in Golaghat district of Assam documented the effectiveness of use of HBNC voucher system in increasing knowledge, awareness, and utilization of different services and suggested that this innovation has the potential for system strengthening by making ASHA more accountable by assisting in planning public health interventions to change the behavior of both caregiver and provider, as it is “easy” and “convenient.”[7]

The India Newborn Action Plan outlines a targeted strategy for accelerating the reduction of preventable newborn deaths and stillbirths in the country for attainment of goals of “single-digit neonatal mortality rate by 2030” and “single-digit stillbirth rate by 2030.”[8] Main person to provide HBNC at the doorstep of people is the ASHA workers under the National Health Mission.[9] Most of the studies done in different parts of India showed that newborn babies were not getting good quality of HBNC as majority of ASHA workers were not able to record temperature, weight the baby correctly, and identify danger signs correctly and nearly one-third of ASHAs did not counsel about handwashing and immunization of newborn.[9],[10],[11],[12] Hence, in this context, the use of voucher system in HBNC has the potential to make ASHAs more accountable and community more aware and participatory.

Scaling up access to home-based neonatal care in India has the potential to avert 57 cases of severe neonatal morbidity, and six-related deaths per 1000 live births reduce out-of-pocket expenditure for treating neonatal morbidity, accruing at a greater rate among people in lower wealth quintiles and those in the poorer states of Chhattisgarh, Uttarakhand, Bihar, Assam, and Uttar Pradesh. In terms of cost per death averted, scaling up the intervention would be cost-saving if both government expenditures on the program and averted private out-of-pocket treatment expenditure are considered. If only government expenditures are considered, the program would be highly cost-effective.[13] However, there are innumerable problems in actual implementation of these strategies.[14]

Globally, during in 2017, only 42% of children (0–23-month-old children) were put to breast within the 1st h which was well below the target set for 2030 (70%). No notable differences were found globally in rates of initiation based on the sex of the child, place of residence (rural or urban), or household wealth.[15],[16],[17],[18] In our study, breastfeeding counseling was done in 57% of cases as informed by beneficiaries. Another study also showed that delivery of quality newborn care can be ensured by giving proper and quality training to ASHA workers regarding HBNC. Furthermore, refresher trainings should be planned regularly for updating skills. This would decrease the knowledge gaps between the learning and doing process.[19]

Some additional information in HBNC voucher which can help in counseling on family planning can be incorporated for improvement of family planning practices and can be tested by further implementation research. Regular refresher training of ASHA on essential newborn care, monitoring and supportive supervision, and improved communication for better community awareness development with better utilization of Village Health and Nutrition Day platform may improve the utilization of this initiative further. As it was a rapid assessment, cross verification of administrative data such as matching the utilization of voucher and payment was not done and can be considered as a limitation of the study.

The process of HBNC voucher initiative is ongoing with good knowledge and practice pattern among service provider and supervisors. However, some areas such as supply chain issues have scope for improvement. This initiative has the potential to improve HBNC practices and to reduce morbidity and mortality of neonates by improving community-based practice pattern.

Financial support and sponsorship

This study was funded by the UNICEF, Assam, India.

Conflicts of interest

There are no conflicts of interest.

   References Top

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Levels&Trends in Child Mortality Estimates, Report 2018, Developed by the UN Inter-Agency Group for Child Mortality Estimation Weblink. Available from : [Last accessed on 2019 Apr 10].  Back to cited text no. 2
United Nations Children's Fund. Toolkit for Setting up of Special Care Newborn Units, Stabilisation Units and Newborn Corners. New Delhi: United Nations Children's Fund; 2008. p. 9. Available from: [Last accessed on 2018 Sep 15].  Back to cited text no. 3
Watkins K. Fair Chance for Every Child. The State of the World's Children. New York: UNICEF; 2016. p. 172. Available from: [Last accessed on 2018 Nov 26].  Back to cited text no. 4
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Ministry of Health and Family Welfare. Home Based Newborn Care Operational Guidelines. New Delhi: Government of India; 2011. Available from: [Last accessed on 2015 Dec 25].  Back to cited text no. 9
Phukan RK, Barman MP, Mahanta J. Factors associated with immunization coverage of children in Assam, India: Over the first year of life. J Trop Pediatr 2009;55:249-52.  Back to cited text no. 10
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Sinha LN, Kaur P, Gupta R, Dalpath S, Goyal V, Murhekar M. Newborn care practices and home-based postnatal newborn care programme – Mewat, Haryana, India, 2013. Western Pac Surveill Response J 2014;5:22-9.  Back to cited text no. 12
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  [Table 1], [Table 2], [Table 3]


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