Introduction:

• Accredited social health activist (ASHA) is a crucial last link to India’s rural healthcare delivery system. 
• It has been 12 years since ASHAS were introduced by the Union government under the National Rural Health Mission (NRHM). 
• She is responsible for maintaining the health of the pregnant women in her community, encouraging them to undergo institutional delivery, ensuring newborns get immunised at the right time and the mother gets the right nutrition after child birth.

Significance

1. Interface between community and Public health system

• The primary role of the volunteer, selected from within the community, is to act as an interface between the community and the public health system.

     2.Range of functions is wide

• Under the scheme guidelines, there are 43 different functions along with specific remuneration for each of them. 
• They range from a maximum of Rs 5,000 for administering medicines to drug-resistant tuberculosis patients to just Rs 1 for distributing an ORS (oral rehydration solution) packet.

      3.Critical in improving maternal and child health

• Several studies credit them for the improvement of critical health indicators in the country. 
• Institutional delivery in Bihar, Madhya Pradesh, Odisha, Rajasthan and Uttar Pradesh increased from 12 per cent in 1992-93 to 55 per cent in 2008 due to the introduction of ASHAs. 
• The role of ASHAs in dramatic turnaround in immunisation numbers and tackling malnutrition is also well documented.

Problems 

1. Low and non-fixed salary

• There are over 0.87 million ASHAs across India 
• In the past three years, ASHAs from at least 17 states have demanded fixed salaries, higher incentives and inclusion in social safety schemes such as pensions
• ASHAs are not recognised as workers and thus get less than Rs 18,000 per month. They are the cheapest healthcare providers in India. 
• ASHAs say they normally earn through antenatal care (Rs 300), institutional delivery (Rs 300), family planning (Rs 150) and immunisation rounds (Rs 100) as cases of other diseases are far and few.

     2.No dedicated fund

• They are paid from the NRHM fund for which they have to wait for long time. The scheme does not have a dedicated budgetary allocation and the funds are arranged on an ad-hoc basis from different government schemes under NRHM such as National Immunisation Programme. 
• The delays in reimbursement of incentives hurt the self esteem of ASHAs and has a bearing on her service delivery.

     3.Abysmal training

• Under the scheme, every ASHA receives induction training where she is given a broad training on healthcare and her role in it. Subsequently, ASHAs should receive regular trainings on specific subjects such as maternal and child health, family planning or HIV-AIDS. 
• The residential trainings at the block-level should happen once every year. 
• In practice, the trainings do not happen regularly.

Way forward

1. Fixed salary and dedicated fund

• A Parliamentary Committee on Empowerment of Women way back in 2010 recommended fixed salaries for ASHAs. 
• There should be a dedicated fund for ASHAs, which will ensure timely payment of the incentives and boost the morale of the volunteers

     2.Skill training

• Skill upgradation should be an integral part of the scheme. 
• Volunteers should be encouraged to take short-term courses on auxiliary nurse mid-wives/general nursing and midwifery. This will not only help the volunteers in getting a better incentive, but will also ensure that the people living in remote areas have better health access. 
• Currently, nursing schools in 11 states give preference to ASHAs for auxiliary nurse mid-wives and general nursing courses.