ASHA: A successful public health experiment rooted in the village community

News: The World Health Organisation (WHO) has recognized the contribution of India’s 1 million Accredited Social Health Activists (ASHAs) during the Covid-19 pandemic

ASHA workers have received the Global Health Leaders Award-2022 in the backdrop of the on-going 75th World Health Assembly.

Genesis of the ASHA worker programme

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.

In many states, ASHAs are involved in national health programmes, and in the response to a range of communicable and non-communicable diseases. They get performance-based payments, not a fixed salary like government servants.

– The idea behind this was to make her a part of the village community rather than a government employee, i.e. to prevent governmentalisation and promote communitisation.

Over 98% ASHAs belong to the village where they reside, and know every household. Their selection involved the community and key resource persons. Educational qualification was a consideration.

With newly acquired skills in health care and the ability to connect households to health facilities, she was able to secure benefits for households. She was like a demand-side functionary, reaching patients to facilities, providing health services nearer home.

In a way, it became a programme that allowed a local woman to develop into a skilled health worker.

The ASHAs brought basic health services to the doorstep of households.

What were the challenges faced by ASHA workers, and how were they addressed?

The ASHAs faced a range of challenges: Where to stay in a hospital? How to manage mobility? How to tackle safety issues?

The solutions were found in a partnership among frontline workers, panchayat functionaries, and community workers.

– The Community Worker added value to this process. Incentives for institutional deliveries and the setting up of emergency ambulance services like 108, 102, etc. across most states built pressure on public institutions and improved the mobility of ASHAs.

There have been challenges with regard to the performance-based compensation. In many states, the payout is low, and often delayed.

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.

What is the way forward?

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.

Source: This post is based on the article “ASHA: A successful public health experiment rooted in the village community” published in The Indian Express on 24th May 22.