ASHA Workers

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GS 2 >> Social Justice >> Public Health > Primary healthcare

REFERENCE NEWS

The recent protest by Accredited Social Health Activist (ASHA) workers in Bengaluru underscores persistent concerns surrounding their working conditions and pay, shedding light on challenges within India's rural healthcare system.

WHO ARE ASHA WORKERS?

• ASHA 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.
• ASHA workers were instituted as community-based health functionaries under the National Rural Health Mission (NRHM) launched in 2005.
• 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.
• They act as a bridge connecting marginalised communities with facilities such as primary health centres, sub-centres and district hospitals.
• 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.
• 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 the programme guidelines.
• ASHA worker earns around 6,000-8,000 per month, including monthly honorarium from the Central and State governments, and incentives.

ASHA WORKERS' CONTRIBUTIONS TO THE HEALTH CARE SYSTEM IN THE COUNTRY:

• Create awareness about health and promote good health practices:
  • ASHA will be a health activist in the community who will create awareness on health and its social determinants and mobilise the community towards local health planning and increased utilisation and accountability of the existing health services.
  • She would be a promoter of good health practices and will also provide a minimum package of curative care as appropriate and feasible for that level and make timely referrals.
  • ASHA will provide information to the community on determinants of health such as nutrition, basic sanitation & hygienic practices, healthy living and working conditions, information on existing health services and the need for timely utilisation of health & family welfare services.
• Maternal and child health:
  • ASHA workers ensure that women undergo ante-natal check-up, maintain nutrition during pregnancy, and deliver at a healthcare facility. Also they provide post-birth training on breast-feeding and complementary nutrition of children.
  • ASHA workers are also tasked with ensuring and motivating children to get immunised.
  • They also counsel women about contraceptives and sexually transmitted infections.
• Pandemic response:
  • 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.
  • ASHA workers have helped in spreading awareness at the grassroots level during the COVID-19 pandemic. They are tasked with informing their local communities about safety protocols and carrying out the vaccination drive.
• The first port of call for health related demands:
  • ASHA will be the first port of call for any health related demands of deprived sections of the population, especially women and children, who find it difficult to access health services.
  • Empowered with knowledge and a drug-kit to deliver first-contact healthcare, every ASHA is expected to be a fountainhead of community participation in public health programmes in her village.
• Communicable and non-communicable disease management and control:
  • ASHA workers provide medicines daily to TB patients under directly observed treatment of the national programme.
  • They are also tasked with screening for infections like malaria during the season. They also provide basic medicines and therapies to people under their jurisdiction such as oral rehydration solution, chloroquine for malaria, iron folic acid tablets to prevent anaemia, and contraceptive pills.
  • They also get people tested and get their reports for non-communicable diseases.

ISSUES FACED BY ASHA WORKERS:

• Inadequate payment:
  • Unlike Anganwadi workers (AWW) and Auxiliary Nurse Midwife (ANM), ASHA workers do not have a fixed salary. Since they are considered “volunteers”, governments are not obligated to pay them a salary.
  • 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. Also, they do not have opportunity for career progression.
  • These issues have resulted in dissatisfaction, regular agitations and protests by ASHAs in many States of India.
• Social Stigma and related issues:
  • ASHA workers experience stigma not only in public space but also in private sphere.
  • For instance, in most families, women going out is considered a bad thing, and ASHAs are not exempt from this.
  • There are instances where ASHA workers have to experience sexual harassment during field visits.
  • Also, during the pandemic, ASHA workers are being stigmatised as carriers of COVID-19 as they come in contact with many people every day.
  • Also they feel pressure from family to discontinue their work because their honorarium is very low.
  • Despite their hard work, they often face allegations from the community that they are not doing their job properly.
• Absence of social security benefits:
  • Not being classified as ‘employees’, ASHAs do not have access to formal frameworks of social protection. They instead have to rely on ad hoc, temporary welfare measures.
  • For instance, in 2018, the Union Government made ASHAs eligible for life insurance, accident insurance and pension under the following schemes: Pradhan Mantri Jeevan Jyoti Beema Yojana, Pradhan Mantri Suraksha Beema Yojana, Pradhan Mantri Shram Yogi Maan Dhan. However, the free cover under these schemes appears to only have been provided for a period of one year.
  • Frontline workers, including ASHAs, have not been included in the new Code on Social Security, 2020, contrary to the recommendations of the Parliamentary Standing Committee on Labour.

WAY FORWARD:

• Higher remuneration:
  • 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.
• Capacity-building and career progression:
  • In-built institutional mechanisms should be created for capacity-building, and avenues for career progression for ASHAs to move to other cadres such as ANMs, public health nurses, and community health officers should be opened.
  • A few Indian States have started such initiatives but these are smaller in scale and at nascent stages.
• Social security benefits:
  • Extending social security benefits like pensions, EPF, health insurance (for ASHAs and their families), etc., 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.
• Making ASHAs permanent government employees:
  • The government should regularise many temporary posts in the National Health Mission and make 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 the ongoing need for functions being undertaken by ASHAs.
• External review:
  • 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.

ASHA workers play a critical role in bridging healthcare access gaps in India, but face significant challenges including inadequate compensation and lack of social security, underscoring the need for systemic reforms to acknowledge and enhance their contributions.

PRACTICE QUESTION:

Q: ASHA workers have played a pivotal role in decentralizing health services in India. Elaborating on this statement, discuss the challenges faced by them.(10M,150W)