Table 3 Examples of roles and factors influencing collaboration among frontline workers, by intervention type and district

1. Antenatal care services, including maternal IFA supplementation

(75.4% of women with children aged 0–5.9 months received ≥4 ANC visits)

Clear understanding of roles among FLWs; led by health workers. “ASHA will know first who is pregnant in her area because she is always visiting her area. After that, she will inform the ANM to provide service.” (Block health program manager). As part of ANC, AWW registers and weighs women. ANM leads checkups and provides vaccines. ASHA and ANM together provide IFA supplementation.

Most ANC services are provided at VHND, which is the main platform for collaboration among all FLWs.

Clear roles among FLWs; led by ASHA. ASHA convenes all the women, provides counseling, and conducts home-based care. AWW registers and weighs women. ANM conducts checkups. ASHA provides IFA supplementation, with ANM and AWW support.

FLWs know each other’s responsibilities, fill in for each other, and closely communicate about any problems.

ANC during VHND, providing platform for integrated service delivery.

Clear roles among FLWs; led by health workers. ASHA is responsible for calling the beneficiaries. AWW registers pregnant women. ANM is responsible for checkups and providing vaccines and IFA, with support from ASHA.

FLWs fill in for each other, even across sectors.

VHND provides the platform for integrated service delivery.

2. Immunization and vitamin A supplementation

(69.6% of children aged 12–23.9 months received vitamin A)

Clear roles among FLWs; led by ANM. All FLWs involved in preparing beneficiary list; ASHA calls beneficiaries for immunization. ANM administers immunization and vitamin A with ASHA and AWW support.

All FLWs plan and attend monthly immunization sessions together.

Guidelines outlining ASHA and AWW responsibilities exist.

Clear roles among FLWs; led by ANM. “The aim of ICDS is to reduce malnutrition and infant mortality. The health department also has the same objective. 100% immunization is the target of ICDS and health department. So, we have coordination to achieve this common target” (Lady supervisor). All FLWs maintain registry and discuss immunization plans a day prior by phone. ASHA and AWW usually mobilize beneficiaries. ANM administers vaccines and vitamin A with ASHA and AWW support.

Immunization involves joint action planning between Health and ICDS.

FLWs jointly monitor immunization.

FLWs fill in for one another when needed and also coordinate with GKS.

Clear roles among FLWs; led by ANM. ASHA is primarily responsible for calling beneficiaries to immunization, usually at AWC. ANM is responsible for immunization and vitamin A, with support.

Planning, implementation, and monitoring of immunization involve all FLWs.

Lack of training of ICDS staff or the absence of ANM hinders implementation.

3. Pediatric IFA supplementation

(5% of children aged 6–23.9 months received IFA)

AWW responsible. AWW primarily provides IFA syrup at AWC.

AWW responsible to provide pediatric IFA, but stocks irregular.

Roles varied across villages. ASHA and AWW receive stocks of IFA syrup from ANM to administer, often during VHND. Some AWWs provide IFA at AWC.

IFA is always supplied by Health, but distributed by different FLWs. Unclear lead or primarily responsible.

Roles varied across villages. ANM provides IFA syrup with support of ASHA and AWW, or AWW provides IFA at AWC.

IFA is always supplied by Health, but distributed by different FLWs. Unclear lead or primarily responsible.

4. IYCF counseling/education

(32.1% of women with children aged 6–23.9 months received CF information during home visits in last 3 months)

Roles varied across villages. AWW always present for home visits, with either ANM or ASHA, to provide counseling. At VHND, ANM or ASHA counsels.

While all FLWs involved, ASHA specifically trained for IYCF counseling.

Conflicting reports on whether guidelines for home visits exist.

AWW leads home visits; ANM leads at VHND. FLWs coordinate via phone regarding home visits, but AWW conducts home visits most often, with ANM and ASHA support. ANM seen as lead for counseling during VHND, although all FLWs involved.

While all FLWs received IYCF training, AWW considered as not qualified to counsel on her own by health workers. Home visits are often missed due to lack of time.

ANM responsible, but roles varied across villages.

FLWs coordinate home visits, but varied on who conducts. ANM plays lead role in IYCF counseling.

All FLWs reportedly received IYCF training.

FLWs coordinate home visits for IYCF counseling.

5. Growth monitoring and referrals for severe acute malnutrition

(44.6% of children aged 0–5.9 months, and 51.5% aged 6–23.9 months received growth monitoring)

AWW leads with support from other FLWs. AWW is responsible for weighing and plotting growth charts, mainly during VHND. ASHA and ANM support with counseling about growth.

At VHND, AWW weighs and measures and, together with ANM, provides referrals. ASHA usually accompanies referred children to hospital.

VHND is a key platform for coordination.

AWW responsible, often alone. AWW responsible for weighing and preparing charts, mostly during VHND. ASHA or ANM helps in few villages.

AWW fills out referral slips. PRI, SHG, and monitoring committee sometimes help AWW with referrals. ASHA or AWW accompanies referred children.

AWW feels overburdened by growth monitoring large numbers of children alone and asks for more support from ASHA and ANM in this activity.

AWW leads with support from other FLWs. AWW responsible with support from ASHA and ANM. AWW follows up with growth monitoring during home visits if absent on VHND.

At VHND, AWW weighs children, and ANM makes referrals. ASHA accompanies child to Nutrition Rehabilitation Center, sometimes accompanied by AWW.

FLWs fill in for each other.

VHND is key platform for coordination.

Guideline for referrals exists.