An expert explains | ASHA: A successful experience in public health rooted in the village community
The World Health Organization (WHO) has recognized the contribution of India’s One Million Accredited Social Health Activists (ASHA) during the Covid-19 pandemic. ASHAs are recognized as facilitating linkages of households to health facilities and playing a central role in door-to-door surveys, immunization, public health, and reproductive and child health measures.
In many states, ASHAs are involved in national health programs and in the response to a range of communicable and non-communicable diseases. They receive performance-based payments, not a fixed salary like civil servants. There have been agitations demanding employee status for ASHA workers. The idea of performance-based payments was never to pay them a pittance – the compensation had to be substantial.
Genesis and evolution
The ASHA program was based on Chhattisgarh’s successful Mitanin program, in which one community worker serves 50 households. The ASHA was to be a local resident, caring for 200 households. The program had a very strong emphasis on step-by-step capacity building in selected areas of public health. Dr. T Sundararaman and Dr. Rajani Ved, among others, provided significant support to this process. Many states have tried to gradually 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 nurse of public health.
Important public policy and public management lessons emerge from the successful experience with community workers who were not the bottom rung of the government system – rather they belonged to the community and were paid for the services they rendered. The idea was to make her a part of the village community rather than a government employee.
More than 98% of ASHAs belong to the village where they reside and know each household. Their selection involved the community and key resource persons. Educational qualification was a consideration. With her 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 civil servant on the demand side, reaching patients in facilities, delivering health services closer to home.
Building a frame
It is a program that has worked well across the country. As skills improved, recognition and respect for ASHA grew. In a way, it became a program that enabled a local woman to become a qualified health professional.
The ASHAs faced a series of challenges: Where to stay in a hospital? How to manage mobility? How to resolve security issues? The solutions were found in a partnership between frontline workers, panchayat officials and community workers. This process, along with the strengthening of public health infrastructure with flexible funding and innovations under Mission Santé and Health and Wellness Centers, has led to an increase in attendance at public facilities. Accountability has increased; there would be protests if an establishment did not offer quality services.
The community worker added value to this process. Incentives for institutional deliveries and the establishment of emergency ambulance services such as 108, 102, etc. in most states have put pressure on public institutions and improved the mobility of ASHAs. Overall, this created a new cadre of progressively skilled local workers who were paid according to their performance. ASHAs were respected for bringing basic health services to the doorstep of households.
There have been challenges with respect to performance-based compensation. In many states, payment is low and often delayed. The original idea was never to deny ASHA compensation that might be even better than a salary – it was only to prevent “governmentalization” and promote “communitarianization” by making it accountable to the people. that she served.
There were serious debates within the mission steering group, and the late Raghuvansh Prasad Singh made a very passionate plea for fixed fees to ASHAs. Dr. Abhay Bang and others wanted the community character to remain and made an equally strong plea for developing the skills and capacities of community workers. Some states have encouraged ASHAs to move up the human resources/skills ladder by becoming ANMs/GNMs and even nurses after preferential admission to these courses.
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Important public policy lessons are the need to progressively develop a local worker accountable to the community, to make performance-based payments, and to provide a push on the demand side with a simultaneous increase services in public systems. The system can only sustain and grow if compensation is adequate, and ASHA continues to enjoy the trust of the community.
There is a strong case for granting tenure to some of these positions with reasonable pay as a supporting motivation. The progressive development of a local resident is an important factor in the engagement of human resources in community-related sectors. This should also apply to other field staff such as ANMs, GNMs, public health nurses.
Equally important is ensuring that performance pay is timely and adequate. Ideally, an ASHA should be able to earn more than the salary of a government employee, with opportunities to move up the ranks in the formal primary health care system as an ANM/GNM or public health nurse. Upgrading skills 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 subsistence needs at reasonable rates, and coverage under pro-poor social safety net programs will help make ASHAs agents of even more powerful change.
Amarjeet Sinha is a retired civil servant who has been associated with the design and capacity building of the ASHA program for over five years.