Baba’s Explainer – ASHA Workers

• ASHA (which means hope in Hindi) 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.
• They act as a bridge connecting marginalised communities with facilities such as primary health centres, sub-centres and district hospitals.
• 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 idea was to make her a part of the village community rather than a government employee. Over 98 per cent ASHAs belong to the village where they reside, and know every household.
• She was like a demand-side functionary, reaching patients to facilities, providing health services nearer home.
• The role of these community health volunteers under the National Rural Health Mission (NRHM) was first established in 2005.
• 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 NRHM programme guidelines.
• 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.
• Capacity building of ASHA is being seen as a continuous process. ASHA will have to undergo series of training episodes to acquire the necessary knowledge, skills and confidence for performing her spelled out roles.

The details task assigned  to ASHA workers under National Health Mission

• To create awareness and provide information to the community on determinants of health such as nutrition, basic sanitation & hygienic practices and health services.
• To counsel women and families on birth preparedness and to ensure that 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.
• To counsel women about contraceptives and sexually transmitted infections.
• To ensure and motivate that children in their community gets immunised.
• To work with the Village Health, Sanitation and Nutrition Committee to develop a comprehensive village health plan, and promote convergent action by the committee on social determinants of health. In support with VHSNC, ASHAs will assist and mobilize the community for action against gender based violence.
• To provide community level curative care for minor ailments such as diarrhoea, fevers, care for the normal and sick newborn, childhood illnesses and first aid.
  • She will be a provider of Directly Observed Treatment Short-course (DOTS) under Revised National Tuberculosis Control Programme.
  • She will also act as a depot holder for essential health products appropriate to local community needs. A Drug Kit will be provided to each ASHA.
• To act as a care provider can be enhanced based on state needs. States can explore the possibility of graded training to the ASHA to provide palliative care, screening for non communicable diseases, childhood disability, mental health, geriatric care and others.
• To provide information on about the births and deaths in her village and any unusual health problems/disease outbreaks in the community to the Sub-Centres/Primary Health Centre.
• She will promote construction of household toilets under Total Sanitation Campaign.
• On top of that ASHA workers were given so much work during the pandemic.

To summarise, her job responsibilities are three-fold

• role of a link-worker (facilitating access to healthcare facilities and accompanying women and children)
• community health worker (depot-holder for selected essential medicines and responsible for treatment of minor ailments),
• health activist (creating health awareness and mobilizing the community for change in health status)

• ASHA workers were a key part of the government’s pandemic response, with most states using the network for screening people in containment zones, getting them tested, and taking them to quarantine centres or help with home quarantine.
• During the first year of the pandemic, when everyone was scared of the infection, ASHA workers had to go door-to-door and check people for Covid-19 symptoms. They had to inform the authorities and help the people reach the quarantine centres.
  • ASHA workers faced a lot of harassment because there was so much stigma about the infection that people did not let them in.
• ASHA workers had to go to households with confirmed Covid-19 cases and explain the quarantine procedure. They had to provide them with medicines and pulse-oximeters. All of this on top of their routine work.
• With the vaccination drive for Covid-19 beginning in January 2021, they have also been tasked with motivating people to get their shots and collect data on how many people are yet to get vaccinated.

• The ASHAs were respected as they brought basic health services to the doorstep of households.
• Community health volunteer is considered vital to achieving the goal of increasing community participation and access to the healthcare system. Their role led to increased footfall in government facilities.
• Accountability of public health services increased; there would be protests if a facility did not extend quality services.
• 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.
• Overall, it created a new cadre of incrementally skilled local workers who were paid based on performance.
• Needless to say, ASHA workers contributed towards curbing the spread of COVID-19 pandemic.

• Work burden hardly makes it Voluntary in nature: Their job description keeps expanding to include more tasks. There are multiple tasks that they have to do on a daily basis. Most of them don’t consider it as “voluntary” work that could be done based on how much time they had, rather as duties that any regular employee has to perform.
  • “Her work would be so tailored that it does not interfere with her normal livelihood,” the National Health Mission states pointing towards the volunteer nature of the role envisaged.
• Grossly Underpaid: Since they are considered “volunteers”, governments are not obligated to pay them a salary. They were paid incentives for different tasks undertaken by them with no fixed wage component. It added up to anywhere between Rs 6,000 to Rs 8,000 a month (less than the wages of unskilled manual labour under MGNREGA). Additionally, there is a lot of variation in what they get paid in different states. To make matters worse, they have to cope with delays in payment, poor infrastructure and transport and so on.
  • The intention of providing incentives rather than salary was to prevent “governmentalisation”, and promote “communitisation” by making her accountable to the people she served.
• No Provision for Safety Nets: They do not get any benefits like pension or health insurance. The chronic lack of attention to their working conditions only serves to weaken policy outcomes, women’s empowerment and community development over all.
• Debate over Status: There is a strong argument to grant permanence to some of these positions with a reasonable compensation as sustaining motivation. For quite some time now, ASHA workers have been demanding that they be made permanent employees of the government and provided benefits.
• Lack of Skill Ladder: There is also a strong plea for skill and capacity development of Community Workers so that they move up the skill ladder in the formal primary health care system as an ANM/ GNM or a Public Health Nurse.

• Given the declining female labour force participation, the government’s recognition of front-line workers and their contribution to human development is an urgent requirement.
• The central role that these workers have been playing in the COVID-19 pandemic could become an opportunity for recognition of their work and initiate a process where their work conditions are improved.
• The system can sustain and grow only if the compensation is adequate, and the ASHA continues to enjoy the confidence of the community.
• Expanding better opportunities with decent wages for front-line workers is not only necessary for acknowledging their rights as workers, but could also contribute to the revival of the rural economy by putting wages into the hands of many ASHA workers.