Context: Recently, World Health Organisation has recognized the country’s 10.4 lakh ASHA (Accredited Social Health Activist) workers as ‘Global Health Leaders’ for their efforts in connecting the community to the government’s health programs.

ASHA workers

• They are volunteers from within the community who are trained to provide information and aid people in accessing the benefits of various healthcare schemes of the government.
• The role of these community health volunteers under the National Rural Health Mission (NRHM) was first established in 2005.
• They act as a bridge connecting marginalized communities with facilities such as primary health centers, sub-centers, and district hospitals.
• They are primarily married, widowed, or divorced women between the ages of 25 and 45 years from within the community.

As per the program guidelines

• They should have good communication and leadership skills.
• They should be literate with formal education up to Class 8.

Current status of ASHA

• There are around 10.4 lakh ASHA workers across the country, with the largest workforces in states with high populations – Uttar Pradesh (1.63 lakh), Bihar (89,437), and Madhya Pradesh (77,531).
• Goa is the only state with no such workers, as per the latest National Health Mission data available from September 2019.
• The aim is to have one ASHA for every 1,000 persons or per habitation in hilly, tribal, or other sparsely populated areas.

Genesis & evolution

• The ASHA program was based on Chhattisgarh’s successful Mitanin program, in which a Community Worker looks after 50 households.
• The ASHA was to be a local resident, looking after 200 households.
• The program had a very robust thrust on the stage-wise development of capacity in selected areas of public health.

What do ASHA workers do?

• They go door-to-door in their designated areas creating awareness about basic nutrition, hygiene practices, and the health services available.
• They focus primarily on ensuring that women undergo ante-natal check-ups, maintain nutrition during pregnancy, deliver at a healthcare facility, and provide post-birth training on breastfeeding and complementary nutrition for children.
• They also counsel women about contraceptives and sexually transmitted infections.
• They are also tasked with ensuring and motivating children to get immunized.
• Other than mother and child care, ASHA workers also provide medicines daily to TB patients under directly observed treatment of the national program.
• They are also tasked with screening for infections like malaria during the season.
• They also provide basic medicines and therapies to people under their jurisdiction such as oral rehydration solution, chloroquine for malaria, iron-folic acid tablets to prevent anemia, and contraceptive pills.

How much are ASHA workers paid?

• Governments are not obligated to pay them a salary.
• Their income depends on incentives under various schemes that are provided when they, for example, ensure an institutional delivery or when they get a child immunized.

What have been the public policy lessons from the ASHA worker programme?

The important public policy lessons are –

• the need to incrementally develop a local worker keeping accountability with the community,
• make performance-based payments, and
• provide a demand-side push with simultaneous augmentation of services in public systems. The system can sustain and grow only if the compensation is adequate, and the ASHA continues to enjoy the confidence of the community.

Road Ahead

• There is a strong argument to grant permanence to some of these positions with a reasonable compensation as sustaining motivation.
• The incremental development of a local resident woman is an important factor in human resource engagement in community-linked sectors. This should apply to other field functionaries such as ANMs, GNMs, Public Health Nurses as well.
• It is equally important to ensure that compensation for performance is timely and adequate.
• Ideally, an ASHA should be able to make more than the salary of a government employee, with opportunities for moving up the skill ladder in the formal primary health care system as an ANM/ GNM or a Public Health Nurse.
• Upgrading skill sets and providing easy access to credit and finance will ensure a sustainable opportunity to earn a respectable living while serving the community.
• Strengthening access to health insurance, credit for consumption and livelihood needs at reasonable rates, and coverage under pro-poor public welfare programmes will contribute to ASHAs emerging as even stronger agents of change.

By: Shubham Tiwari