The country’s frontline health workers or ASHAs (accredited social health activists) were one of the six recipients of the WHO’s Global Health Leaders Award 2022 which recognises leadership, contribution to the advance of global health and commitment to regional health issues.

Who are ASHA workers?

• ASHA workers are volunteers from within the community who are trained to provide information and aid people in accessing 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 marginalised communities with facilities such as primary health centres, sub-centres and district hospitals.

Genesis & evolution

• The ASHA programme was based on Chhattisgarh’s successful Mitanin programme, in which a Community Worker looks after 50 households.
• The ASHA was to be a local resident, looking after 200 households.
• The programme had a very robust thrust on the stage-wise development of capacity in selected areas of public health.
• Many states tried to incrementally develop the ASHA from a Community Worker to a Community Health Worker, and even to an Auxiliary Nurse Midwife (ANM)/ General Nurse and Midwife (GNM), or a Public Health Nurse.

Qualifications for ASHA Workers

• ASHAs are primarily married, widowed, or divorced women between the ages of 25 and 45 years from within the community.
• They must have good communication and leadership skills; should be literate with formal education up to Class 8, as per the programme guidelines.

How many ASHAs are there across the country?

• The aim is to have one ASHA for every 1,000 persons or per habitation in hilly, tribal or other sparsely populated areas.
• 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.

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 pregnant women undergo ante-natal check-up, maintain nutrition during pregnancy, deliver at a healthcare facility, and provide post-birth training on breast-feeding and complementary nutrition of children.
• They also counsel women about contraceptives and sexually transmitted infections.
• ASHA workers are also tasked with ensuring and motivating children to get immunised.
• Other than mother and child care, ASHA workers also provide medicines daily to TB patients under directly observed treatment of the national programme.
• 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 anaemia etc.
• Now, they also get people tested and get their reports for non-communicable diseases.
• The health volunteers are also tasked with informing their respective primary health centre about any births or deaths in their designated areas.

How much are ASHA workers paid?

• Since they are considered “volunteers/activists”, governments are not obligated to pay them a salary. And, most states don’t.
• 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 immunised.
• All this adds up to only between Rs 6,000 to Rs 8,000 a month.
• Her work is so tailored that it does not interfere with her normal livelihood.

Success of the ASHAs

• It is a programme that has done well across the country.
• In a way, it became a programme that allowed a local woman to develop into a skilled health worker.
• Overall, it created a new cadre of incrementally skilled local health workers who were paid based on performance.
• The ASHAs are widely respected as they brought basic health services to the doorstep of households.
• Since then ASHA continues to enjoy the confidence of the community.

Challenges to ASHAs

• The ASHAs faced a range of challenges: Where to stay in a hospital? How to manage mobility? How to tackle safety issues?
• There have been challenges with regard to the performance-based compensation. In many states, the payout is low, and often delayed.
• It has a problem of responsibility and accountability without fair compensation.
• There is a strong argument to grant permanence to some of these positions with a reasonable compensation as sustaining motivation.
• 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.

Way forward

• The incremental development of a local resident woman is an important factor in human resource engagement in community-linked sectors.
• It is equally important to ensure that compensation for performance is timely and adequate.
• 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.

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