Acknowledging the Contributions of ASHA | 03 Jun 2022

India’s one million Accredited Social Health Activists (ASHA) volunteers have received arguably the biggest international recognition in form of the World Health Organisation’s Global Health Leaders Awards 2022. The ASHAs were among the six awardees announced at the 75^th World Health Assembly in Geneva.

ASHAs have made extraordinary contributions towards enabling increased access to primary health-care services like maternal and child health and immunisation. Despite such a significant contribution, ASHA workers face several issues relating to payment, social security and permanence in jobs.

The WHO recognition for ASHA volunteers is a reminder and an opportunity to further strengthen the ASHA programme from the perspective of ASHA workers.

About ASHA (Accredited Social Health Activist)

When was the ASHA Programme Launched?

• India launched the ASHA programme in 2005-06 as part of the National Rural Health Mission.
  • With the launch of the National Urban Health Mission in 2013, the programme was extended to urban settings as well.
• The core of the ASHA programme has been an intention to build the capacity of community members in taking care of their own health and being partners in health services.

What Inspired ASHA?

• The ASHA programme was inspired from the learnings from two past initiatives:
  • In 1975, a WHO monograph titled ‘Health by the people’
  • In 1978, an international conference on primary health care in Alma Ata (in the then USSR and now in Kazakhstan)
• However, the biggest inspiration for designing the ASHA programme came from the Mitanin initiative of Chhattisgarh (Mitanin meaning ‘a female friend’ in Chhattisgarhi) which had started in May 2002.
  • The Mitanin were the all-female volunteers available for every 50 households and 250 people.

What are the Key Features of an ASHA?

• ASHA is a social health activist in the age group of 25-45 years who serves as the first point of contact to cater any health-related requirements of deprived sections of the rural population including women and children, who pose a difficulty in accessing the health services.
• An ASHA worker comes from the same village where she works. It ensures a sense of familiarity, better community connection and acceptance.
• Generally, there is “1 ASHA per 1000 population”. However, this norm can be relaxed in tribal, hilly and desert areas to “1 ASHA per habitation” depending upon the workload.
• The purpose of having ‘activist’ in ‘ASHA’ is to reflect that they are the community’s representative in the health system, and not the lowest-rung government functionary in the community (as was the perception with the erstwhile Community Health Volunteer).

How Significantly do ASHA Workers Contribute to the Healthcare System of India?

• They create awareness about health determinants by providing information to the people about nutrition, basic sanitation & hygienic practices, healthy living and working conditions, etc.
• ASHA counsels women on birth preparedness, safe delivery’s importance, breastfeeding, contraception, immunization, child care and prevention of Reproductive Tract Infection/Sexually Transmitted Infection (RTIs/STIs).
• ASHA provides primary medical care for minor disorders like fever, diarrhoea and minor injuries.
• They also keep the sub-centres/primary health centres informed about births and deaths in their village and any disease outbreaks/unusual health concerns in the community.

What are the Challenges Faced by ASHAs?

• Inadequate Pay and Job Insecurity: Among the 3As in the rural areas (Anganwadi Workers (AWW), Auxiliary Nurse Midwife (ANM) and ASHA), the ASHAs are the only ones who do not have a fixed salary. They also do not have opportunities for career progression.
  • These issues have resulted in dissatisfaction, regular agitations and protests by ASHAs in many States of India.
  • Moreover, even the workload for the ASHAs is not less; they have to work from morning to night without any place for rest.
• Social Stigma and Humiliation: ASHA workers often experience stigma not only in public space but also in the private sphere; there is often pressure from their to discontinue their work due to very low honorarium.
  • Even from the patients’ families, they often suffer allegations of not doing their job properly.
  • An even more disheartening fact is that ASHA workers have to experience sexual harassment during field visits.
• Unavailability of Facilities: ASHAs reported facing challenges in ensuring access to health services during and immediately after outbreaks of conflict. They experienced difficulty in arranging transport and breakdown of services at remote health facilities.
  • Many ASHAs are working in fragile and conflict-affected settings such as Kokrajhar and Karbi Anglong districts of Assam state. No efforts have yet been made to understand the challenges and vulnerabilities of these volunteers working under such conditions.

What can be done to Improve the Status Quo for ASHA Workers?

• Role of State Governments: The global recognition for ASHAs should be used as an opportunity to review the programme afresh, from a solution perspective.
  • The state governments need to develop mechanisms for higher remuneration for ASHAs.
  • The performance-based incentives should not be interpreted that ASHAs — no matter how much and how hard they work — need to be paid the lowest of all health functionaries.
• Upskilling and Capacity Building: It is time that in-built institutional mechanisms are created for capacity-building and avenues for career progression for ASHAs to move to other cadres such as ANM, public health nurse and community health officers are opened.
  • A few Indian States have started such initiatives but these are smaller in scale and at nascent stages. Implementation at a higher level is required.
• Providing Social Security Benefits: Extending the benefits of social sector services including health insurance (for ASHAs and their families) should be considered.
  • The possibility of ASHAs automatically being entitled and having access to a broad range of social welfare schemes needs to be institutionalised.
• Bringing Permanence in Jobs: There are arguments for the regularisation of many temporary posts in the National Health Mission and making ASHAs permanent government employees.
  • Considering the extensive shortage of staff in the workforce at all levels, and more so in the primary health-care system in India, and an ongoing need for functions being undertaken by ASHAs, it is a policy option that is worth serious consideration.
• Incentivising ASHAs in Conflicted Areas: The governments at state and central level first need to recognize the challenges and vulnerabilities that ASHAs working in conflicted areas continue to experience.
  • The health administration shall consider incentivising the ASHAs when they provide services during conflicts.
  • They must not be forgetful of the fact that ASHA workers deserve adequate training, support, recognition, and compensation for the tasks they are carrying out in areas and situations where other cadres and workers are simply unavailable.
  • Psychological support for these community health workers is also equally essential.

Conclusion

Even though they contribute significantly to better health outcomes, the ASHA workforce continues to protest across the country, for better remuneration, health benefits and permanent posts. It is the duty of the governmental agencies that employ them to ensure their welfare, safety and security.

While cheerleading about the award is rightfully reaching a crescendo, what matters is how the Government of India serves its last mile health workers who are its feet on the ground.