Building a future for ASHAs, the beacon of hope for millions of women in India

On 22nd May 2022, at the 75th World Health Assembly, India’s Accredited Social Health Activist (ASHAs) received the WHO Director-General’s Global Health Leaders Award. The award recognised the significant impact of ASHAs in ensuring the delivery of primary health services, including, but not limited to maternal and child health care, family planning, nutrition, immunisation and community mobilisation for mitigation of COVID-19.

The world “ASHA”, translates to “hope” in Hindi and in every sense, these frontline women workers are a beacon of hope among remote and underserved communities. Here, they are often the first and only point of contact with the health system for several women. ASHAs play a crucial role in the implementation of government health programs, such as the Janani Suraksha Yojana (JSY), a conditional cash transfer scheme aimed at encouraging women to give birth in a health facility.

They also work closely with other frontline workers like Auxiliary Nurse Midwives (ANMs) and Anganwadi Workers (AWWs) to conduct community-level activities and serve as a critical link between communities and the public health system.

During the pandemic, ASHAs, AWWs and ANMs played a central role in COVID-19 mitigation and community outreach activities. They distributed pamphlets, conducted surveys, deliverd commodities at the doorstep, communicated on COVID-19 prevention, and later mobilised people for vaccination while addressing vaccine hesitancy.

However, several reports suggested that these frontline workers often worked in precarious conditions, in the absence of adequate personal protective equipment such as masks, gloves, and hand sanitisers, which put them at risk of infection.

They also bore the brunt of prevalent myths and misconceptions around the COVID-19 virus, as well as vaccine hesitancy among communities, leading to resistance and backlash from community members.

Despite their significant contribution and role in the public health system, there is a huge gap between the pay scales of ANMs and ASHAs, who are recruited on a contractual basis under the National Health Mission (NHM). ASHAs are considered volunteers, but the Government of India has introduced a performance-based payment method to support them in achieving defined health objectives.

However, ASHA’s incentives are centred on activities relating to reproductive and child health, organisation of village outreach and screening for non -communicable diseases. Their incentives get significantly impacted in states that have a low total fertility rates (TFR) and higher usage of private health care facilities. With over 25 states achieving replacement level fertility, according to the fifth National Family Health Survey (2019-21), incentive structures need to be re-evaluated.

ASHAs have also been included by the government in its e-Shram programme, which has been created with the objective of providing social security to a database of workers from the informal sector. This contradicts the criticality of their role in the public health system. The Ministry of Health and Family Welfare had assured ASHAs of additional incentives to support the promotion of COVID-19 messaging, contact tracing, and linking of patients with hospitals. ,

However, disbursements varied across states. In 2020, amidst the first wave of the pandemic in 2020, about 6 lakh ASHA workers protested against their low compensation and demanded personal protective measures, given the risky conditions they were working in.

ASHAs serve as the foundation of India's public health system. Yet, the challenges faced by them are numerous and complex. It is important to invest in their capacity building and multi-skilling so that they are better trained to address the health needs of the population.

They need to be equipped with social security, a fixed and enhanced monthly remuneration which justifies their time and effort in addition to the incentive packages provided to them. A clear career progression path for ASHAs is also imperative and their wide-ranging experience working with the community and the health system should be recognised and rewarded.

With the right support and recognition from the government and other stakeholders, these dedicated health workers can continue to provide vital services to the communities they serve and help build a stronger, more resilient public health system.

(Disclaimer: The views and opinions expressed in this article are those of the author and do not necessarily reflect the views of YourStory.)