An Expert Explains | ASHA: A successful public health experiment rooted in the village community

The World Health Organization (WHO) has recognized the contribution of one million accredited Social Health Activists in India (ASHAs) during the Covid-19 pandemic. It is recognized that ASHAs facilitate the connection of families to health facilities, and play pivotal roles in house-to-house surveys, immunization, public health and reproductive and child health measures.

In many countries, ASHAs are involved in national health programs, and in response to a range of communicable and non-communicable diseases. They get paid based on performance, not a fixed salary like government employees. There have been moves to demand employee status for ASHA workers. The idea of ​​performance-based payments was not to pay them a pittance – the compensation was expected to be substantial.

formation and development

ASHA’s program was based on the successful Mitanin program in Chhattisgarh, where a community worker looks after 50 families. ASHA was to be locals, taking care of 200 families. The program has had a very strong impetus in the phased development of capacity in selected areas of public health. Dr. T Sundharaman and Dr. Rajani Vaid among others provided a lot of support for this operation. Many states have attempted to gradually develop ASHA from a community worker to a community health worker, and even to an assistant nurse midwife (ANM)/general nurse and midwife (GNM), or public health nurse.

Important lessons in public policy and public administration emerge from successful experience with community workers who were not the last rung of the government system—but were from the local community, and were paid for the services they provided. The idea was to make her a part of the village community rather than a government employee.

More than 98 percent of ASHAs belong to the village they reside in, and they know each family. Their selection included the community and key professionals. Educational qualification was a consideration. With newly acquired skills in healthcare and the ability to connect families to health facilities, she has been able to secure benefits for families. She worked as a demand side employee, reaching patients to facilities, and providing health services close to home.

cadre building

It’s a program that has done well across the country. As skill sets have improved, so has recognition and respect for ASHA. In a way, it became a program that allowed local women to develop into a skilled health worker.
The ASHAs faced a host of challenges: Where do you stay in the hospital? How do you manage mobility? How do you handle safety issues? Solutions are found in partnership between frontline workers, panchayat employees and community workers. This process, along with strengthening the public health infrastructure with flexible funding and innovations under the mission of health and health and wellness centers, has led to an increased uptake of government facilities. increased accountability; There will be protests if the facility does not provide quality services.

The societal factor added value to the process. Incentives for institutional delivery and establishment of emergency ambulance services such as 108, 102, etc. across most states have increased pressure on public institutions and improved the mobility of ASHAs. Overall, it created a new cadre of increasingly skilled local workers who were paid based on performance. ASHA was respected for bringing essential health services to their doorsteps.

Compensation version

There were challenges with respect to performance-based compensation. In many states, the yield is low and often delayed. The original idea was not to deny ASHA a compensation that could be better than a salary – the goal was just to prevent “governance”, and to promote “participation” by making it accountable to the people it serves.

There were serious discussions in the mission’s steering group, and the late Raghuvansh Prasad Singh made a very passionate plea for a steady reward to the ASHAs. Dr. Abhay Bang and others wanted the survival of the character of the community, and they made an equally strong plea for the development of the skills and capabilities of community workers. Some states have motivated ASHAs to move up the human resources/skills ladder by becoming ANMs/GNMs and even staff nurses after preferential admission to such courses.

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Important public policy lessons are the need to gradually develop a local factor while maintaining accountability with the community, offering performance-based payments, and providing a demand-side boost while simultaneously enhancing services in public systems. The system can only survive and grow if compensation is adequate, and ASHA continues to enjoy the trust of the community.

The controversy over the situation

There is a strong case for giving permanence to some of these jobs with reasonable compensation as a supporting incentive. The gradual development of local resident women is an important factor in the participation of human resources in sectors related to the local community. This should apply to other field personnel such as ANMs, GNMs and public health nurses as well.

It is equally important to ensure that compensation for performance is timely and adequate. Ideally, an ASHA should be able to earn more than a government employee’s salary, with opportunities to move up the skills ladder in the formal primary health care system as an ANM/GNM or public health nurse. Developing skill sets and providing easy access to credit and finance will ensure a sustainable opportunity to earn a decent living while serving the community. Enhancing access to health insurance, credit for consumption and livelihood needs at reasonable rates, and coverage under pro-poor public welfare programs will contribute to the emergence of ASHAs as stronger agents of change.

Amarjit Sinha is a retired civil servant who has been associated with the design and capacity building of the ASHA program for more than five years.

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