Context

India’s one million Accredited Social Health Activists (ASHA) volunteers have received World Health Organization’s Global Health Leaders Awards 2022.

Background of the ASHA program

• In 1975, a WHO monograph titled ‘Health by the people’ and then in 1978, an international conference on primary health care in Alma Ata (in the then USSR and now in Kazakhstan), gave emphasis for countries recruiting community health workers to strengthen primary health-care services that were participatory and people centric.
• Soon after, many countries launched community health worker programmes under different names.
• India launched the ASHA programme in 2005-06 as part of the National Rural Health Mission.
• The biggest inspiration for designing the ASHA programme came from the Mitanin (meaning ‘a female friend’ in Chhattisgarhi) initiative of Chhattisgarh, which had started in May 2002.
• 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.
• Each of these women-only volunteers work with a population of nearly 1,000 people in rural and 2,000 people in urban areas, with flexibility for local adjustments.

A well thought through and deliberated program

• The ASHA programme was well thought through and deliberated with public health specialists and community-based organisations from the beginning.
• 1] Key village stakeholders selected: The ASHA selection involved key village stakeholders to ensure community ownership for the initiatives and forge a partnership.
• 2] Ensure familiarity: ASHAs coming from the same village where they worked had an aim to ensure familiarity, better community connect and acceptance.
• 3] Community’s representative: The idea of having activists in their name was to reflect that they were/are the community’s representative in the health system, and not the lowest-rung government functionary in the community.
• 4] Avoiding the slow process of government recruitment: Calling them volunteers was partly to avoid a painfully slow process for government recruitment and to allow an opportunity to implement performance-based incentives in the hope that this approach would bring about some accountability.

Contribution of ASHA

• It is important to note that even before the COVID-19 pandemic, ASHAs have made extraordinary contributions towards enabling increased access to primary health-care services; i.e. maternal and child health including immunisation and treatment for hypertension, diabetes and tuberculosis, etc., for both rural and urban populations, with special focus on difficult-to-reach habitations.
• Over the years, ASHAs have played an outstanding role in making India polio free, increasing routine immunisation coverage; reducing maternal mortality; improving new-born survival and in greater access to treatment for common illnesses.

Challenges

• Linkages with AWW and ANM: When newly-appointed ASHAs struggled to find their way and coordinate things within villages and with the health system, their linkage with two existing health and nutrition system functionaries — Anganwadi workers (AWW) and Auxiliary Nurse Midwife (ANM) as well as with panchayat representatives and influential community members at the village level — was facilitated.
•  This resulted in an all-women partnership, or A-A-A: ASHA, AWW and ANM, of three frontline functionaries at the village level, that worked together to facilitate health and nutrition service delivery to the community.
• No fixed salary to ASHAs: Among the A-A-A, ASHAs are the only ones who do not have a fixed salary; they do not have opportunity for career progression.
• These issues have resulted in dissatisfaction, regular agitations and protests by ASHAs in many States of India.

Way forward

• The global recognition for ASHAs should be used as an opportunity to review the programme afresh, from a solution perspective.
• 1] Higher remuneration: Indian States need to develop mechanisms for higher remuneration for ASHAs.
• 2] Avenues for career progression: 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.
• 3] Extend the benefits of social sector services: Extending the benefits of social sector services including health insurance (for ASHAs and their families) should be considered.
• 4] Independent and external review: While the ASHA programme has benefitted from many internal and regular reviews by the Government, an independent and external review of the programme needs to be given urgent and priority consideration.
• 5] Regularisation of temporary posts: There are arguments for the regularisation of many temporary posts in the National Health Mission and making ASHAs permanent government employees.

Conclusion

The WHO award for ASHA volunteers is a proud moment and also a recognition of every health functionary working for the poor and the underserved in India.  It is a reminder and an opportunity to further strengthen the ASHA programme for a stronger and community-oriented primary health-care system.

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