India’s one million Accredited Social Health Activists (ASHA) volunteers have received arguably the biggest international recognition in form of the World Health Organization’s Global Health Leaders Awards 2022. The ASHAs were among the six awardees announced at the 75th World Health Assembly in Geneva. This World Health Organization (WHO) award is in recognition of the work done by ASHA volunteers during the COVID-19 pandemic as well as for serving as a link between communities and health systems.
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.
Genesis of the programme
India launched the ASHA programme in 2005-06 as part of the National Rural Health Mission. Initially rolled out in rural areas, with the launch of the National Urban Health Mission in 2013, it was extended to urban settings as well. 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. 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.
The ASHA programme was inspired from the learnings from two past initiatives: one from the late 1970s and the other of the early 2000s. 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. In India, they were called community health volunteers. However, within a few years of implementation, the community health volunteer scheme met many hurdles and evaluations which followed, indicating that a key reason for sub-optimal success was a failure of community health volunteers to make a community connect (in fact, people did not perceive them to be any different from existing government staff). The lack of political will was another factor behind scaling down, before the community health volunteer programme was forgotten.
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 Mitanin were/are all-female volunteers available for every 50 households and 250 people. Public health experts and civil society organisations who had first-hand experience in developing and designing the Mitanin programme were also involved in developing the ASHA programme.
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The ASHA programme was well thought through and deliberated with public health specialists and community-based organisations from the beginning. One, the ASHA selection involved key village stakeholders to ensure community ownership for the initiatives and forge a partnership. Two, ASHAs coming from the same village where they worked had an aim to ensure familiarity, better community connect and acceptance. Three, 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 (as was the perception with the erstwhile community health volunteer, a few decades ago). Four, 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. A practical aspect was that performance-based incentives were being rolled out for the first time in the health services on such a scale. The thinking was that it would be easier to implement performance-based incentives under a new programme and a new workforce rather than for the existing government staff.
Since the launch of ASHA initiatives, many reviews and field assessments have documented successes and learnings. Public health experts have unusual consensus that ASHAs have become pivotal to nearly every health initiative at the community level and are integral to demand side interventions for health services in India.
A partnership, hurdles
However, the programme has had its own set of challenges, which have been tackled proactively and in a timely manner, through sustained political will and by creating institutional mechanisms, i.e. community actions for health and ASHA mentoring groups. For example, 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. Platforms such as village health, sanitation and nutrition committees were created, for coordination and service delivery. In the process, the trio became a well-recognised and respected face of primary health-care services to the community; their working together ensured greater internal accountability. In 2022, it is difficult to imagine how India would have responded to the COVID-19 pandemic had the ASHAs, AWWs and ANMs not toiled.
Yet, there are ongoing challenges that need urgent resolution. 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. Though performance-based incentives are supplemented by a fixed amount in a few Indian States, the total payment continues to remain low and often delayed. These issues have resulted in dissatisfaction, regular agitations and protests by ASHAs in many States of India.
The global recognition for ASHAs should be used as an opportunity to review the programme afresh, from a solution perspective. First, Indian States need to develop mechanisms for higher remuneration for ASHAs. The performance-based incentives should not be interpreted that ASHAs — no matter how much and how hard they work — need to be paid the lowest of all health functionaries. If they work more, the system should allow them to be paid more than even regular government staff.
Second, 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. A few Indian States have started such initiatives but these are smaller in scale and at nascent stages.
External review needed
Third, extending the benefits of social sector services including health insurance (for ASHAs and their families) should be considered. The possibility of ASHAs automatically being entitled and having access to a broad range of social welfare schemes needs to be institutionalised.
Fourth, 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.
Fifth, there are arguments for the regularisation of many temporary posts in the National Health Mission and making ASHAs permanent government employees. Considering the extensive shortage of staff in the workforce at all levels, and more so in the primary health-care system in India, and an ongoing need for functions being undertaken by ASHAs, it is a policy option that is worth serious consideration. Alongside, there is a need to acknowledge that the specific functions at the village level, which ASHAs play, may not be ideally suited for a permanent position. However, finding a middle path would not be very difficult either.
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 an acknowledgement of the role and the relevance of people-centric primary health-care services. It is a reminder and an opportunity to further strengthen the ASHA programme for a stronger and community-oriented primary health-care system, which will prepare India for future epidemics and pandemics as well.
Dr. Chandrakant Lahariya is a primary-care physician and public health specialist. He has been involved in the implementation of the National (Rural) Health Mission in India since inception. E-mail: c.lahariya@gmail.com
