Public health programmes have a long history of working with community health workers. In India, Accredited Social Health Activist (ASHAs) are health workers selected from the village and trained to work on health issues. At the time that these workers were introduced (2005-6) there was much debate surrounding them. Some celebrated this as recognition that community health workers can have an impact on health. Others saw this as bringing health services closer to people. Some others expressed misgivings on the nature of “volunteer” work expected of ASHAs and incentive or piece-rate based engagement especially because it was indicative of how patriarchal institutions compensate ‘women’s’ work and their view of women as workers. Still others saw this as an investment in women and opportunities for leadership. Evidence and experience backed most of these perspectives. What these usually divided groups seemed to agree on is the irony of the state introducing a cadre of “accredited activists”!
In the past decade states have selected, trained and worked with ASHAs in different ways. While ASHAs responsibilities are listed on the National Health Mission website, the gamut is very vast to be truly realised. However, the experience has been different from state to state and there is also a difference overall in the achievements under different health indicators.
ASHA worker, Sanjulata Dehuri, informing mothers about the criticality of monitoring a newborn baby’s temperature, at a Gram Kalyan Samiti meeting facilitated by AIF’s MANSI program in Dhanaguru village, Keonjhar District, Odisha.
Photograph by Prashant Panjiar
Broadly, one can see that ASHAs across the country work on a range of public health issues like reproductive, maternal and child health, family planning, vector borne diseases, communicable diseases, sanitation etc. They are expected to encourage communities to adopt specific behaviours, enhance demand generation and service uptake, perform tests, provide basic drugs, refer and accompany patients to health care facilities. Overall, they are the first point of contact with the village, which over time has meant that they are at the beck and call of the public health system and many other programmes which require village level facilitation! Being at the lowest rung of the health system they are also at a position of disadvantage within their work associations. While fulfilling all these responsibilities, ASHAs often work against very deep seated social norms in deeply patriarchal societies and institutions. She visits homes helping people to adopt new and healthier behaviours while they are faced with multiple other competing priorities and beliefs.
Amidst all of these challenges, as recorded in multiple programme reviews and studies ASHAs contribution have been commendable in some aspects[1] and disappointing in others. The annual Common Review Missions have listed the ASHAs contributions in maternal and newborn care. These and other studies and reviews also highlight that much of the weakness in their performance is linked to larger systemic barriers and shortcomings.
ASHAs in many contexts work not just for the activities under the health department but are points of contact for many development activities at the village level. These is a trend visible across many programmes which work with health workers. The theme of the 1st International Symposium on Community Health Workers held in Uganda was – Contribution of Community Health Workers in attainment of the Sustainable Development Goals. Evidence presented at the conference show cases that community health workers contribute directly to at least seven Sustainable Development Goals.
Today, India has close to 9 lakh ASHAs and in many states, they have started mobilising around their rights as workers. While this coming together to demand rights seems to have become more public and political in the past few years, the discontent is much older. State governments have responded and a few small gestures such as increase in incentives or introduction of ‘benefits’ can be seen. Uttar Pradesh provides incentives like as mobile phones, talk-time or phone recharges are provided in Arunachal Pradesh, Jammu and Kashmir and few other states provide insurance and Kerala, Bihar, Tripura, Maharashtra and Jharkhand have made provision for preferential selection of ASHAs in ANM/ GNM training schools.[2] However, these measures are inadequate and largely dependent on the benevolence of individual states.
ASHAs – the almost paradox like ‘As’ their titles “Accredited” and “Activist” are more clearly visible now as they take to the streets in protest. The past few years have seen a rise in agitations and protests[3] in states like Uttar Pradesh[i], Gujarat[4][5], Karnataka[6] and Andhra Pradesh[7]. The need for discussion on the nature of roles and terms of engagement is evident, the programme evidence and the public protests point to it.
There are no simple answers and there is a decade of experience to reflect on.
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[1] Tripathy, Prasanta, Nirmala Nair, Rajesh Sinha, Shibanand Rath, Raj Kumar Gope, Suchitra Rath, Swati Sarbani Roy, Aparna Bajpai, Vijay Singh, Vikash Nath, Sarfraz Ali, Alok Kumar Kundu, Dibakar Choudhury, Sanjib Kumar Ghosh, Sanjay Kumar, Rajendra Mahapatra, Anthony Costello, Edward Fottrell, Tanja A J Houweling, and Audrey Prost. “Effect of Participatory Women’s Groups Facilitated by Accredited Social Health Activists on Birth Outcomes in Rural Eastern India: A Cluster-randomised Controlled Trial.” The Lancet Global Health 4.2 (2016)
[2] “10th Common Review Mission – Government of India.” National Rural Health Mission. N.p., n.d. Web. 24 Nov. 2017.
[3]Mishra, Ishita. “In Uttar Pradesh, ASHA Workers Have Been Protesting Low Wages and Delayed Payments. Who’s Listening?” Scroll.in. Https://scroll.in, 06 June 2017. Web. 24 Nov. 2017.
[4]Trivedy, Shikha. “In Gujarat Election, Why The Role And Influence Of ASHA Workers Matters.”NDTV.com. N.p., 03 Nov. 2017. Web. 24 Nov. 2017.
[5]Dhar, Damayantee. “Gujarat ASHA Workers’ Protest Ends, But Not Their Struggle for Better Conditions.” The Wire. N.p., 31 Oct. 2017. Web. 24 Nov. 2017.
[6]R, Sunitha Rao. “Asha Workers Demand Salary for Their Work – Times of India.” The Times of India. City, 07 Sept. 2017. Web. 24 Nov. 2017.
[7] “Asha Workers Demand Wage Hike.” The Hindu. N.p., 11 Sept. 2017. Web. 24 Nov. 2017.
