Why ASHA workers generally faces social stigma and humiliation in society?

• Among the 3As in the rural areas (Anganwadi Workers (AWW), Auxiliary Nurse Midwife (ANM) and ASHA), the ASHAs are the only ones who do not have a fixed salary. They also do not have opportunities for career progression.
• These issues have resulted in dissatisfaction, regular agitations and protests by ASHAs in many States of India.
• Moreover, even the workload for the ASHAs is not less; they have to work from morning to night without any place for rest.
• Social Stigma and Humiliation: ASHA workers often experience stigma not only in public space but also in the private sphere; there is often pressure from their to discontinue their work due to very low honorarium.
• Even from the patients’ families, they often suffer allegations of not doing their job properly.
• An even more disheartening fact is that ASHA workers have to experience sexual harassment during field visits.
• Unavailability of Facilities: ASHAs reported facing challenges in ensuring access to health services during and immediately after outbreaks of conflict. They experienced difficulty in arranging transport and breakdown of services at remote health facilities.
• Many ASHAs are working in fragile and conflict-affected settings such as Kokrajhar and Karbi Anglong districts of Assam state. No efforts have yet been made to understand the challenges and vulnerabilities of these volunteers working under such conditions.

• Role of State Governments: The global recognition for ASHAs should be used as an opportunity to review the programme afresh, from a solution perspective.
• The state governments 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.
• Upskilling and Capacity Building: It is time that in-built institutional mechanisms are created for capacity-building and avenues for career progression for ASHAs to move to other cadres such as ANM, public health nurse and community health officers are opened.
• A few Indian States have started such initiatives but these are smaller in scale and at nascent stages. Implementation at a higher level is required.
• Providing Social Security Benefits: Extending the benefits of social sector services including health insurance (for ASHAs and their families) 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.
• Bringing Permanence in Jobs: There are arguments for the regularisation of many temporary posts in the National Health Mission and making 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 an ongoing need for functions being undertaken by ASHAs, it is a policy option that is worth serious consideration.
• Incentivising ASHAs in Conflicted Areas: The governments at state and central level first need to recognize the challenges and vulnerabilities that ASHAs working in conflicted areas continue to experience.
• The health administration shall consider incentivising the ASHAs when they provide services during conflicts.
• They must not be forgetful of the fact that ASHA workers deserve adequate training, support, recognition, and compensation for the tasks they are carrying out in areas and situations where other cadres and workers are simply unavailable.
• Psychological support for these community health workers is also equally essential.

When was the ASHA Programme Launched?

• India launched the ASHA programme in 2005-06 as part of the National Rural Health Mission.
• With the launch of the National Urban Health Mission in 2013, the programme was extended to urban settings as well.
• The core of the ASHA programme has been an intention to build the capacity of community members in taking care of their own health and being partners in health services.
• Many states tried to incrementally 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 Public Health Nurse.
• In many states, ASHAs are involved in national health programmes, and in the response to a range of communicable and non-communicable diseases. They get performance-based payments, not a fixed salary like government servants.
• The idea behind this was to make her a part of the village community rather than a government employee, i.e. to prevent governmentalisation and promote communitisation.
• Over 98% ASHAs belong to the village where they reside, and know every household. Their selection involved the community and key resource persons. Educational qualification was a consideration.
• With 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 demand-side functionary, reaching patients to facilities, providing health services nearer home.
• In a way, it became a programme that allowed a local woman to develop into a skilled health worker.
• The ASHAs brought basic health services to the doorstep of households.

Where ASHA Workers face difficulties during pandemic?

• At the beginning of the COVID-19 pandemic, ASHA workers faced several attacks in different parts of the country during their door-to-door visits for surveillance.
• ASHA workers were responsible for finding symptomatic patients and people with international or domestic travel history, and executing other tasks related to containment of the spread of the virus. They performed these tasks for no additional payment.
• Despite the added responsibilities and demands for increased incentives, ASHA workers complained of not receiving adequate compensation throughout the pandemic.
• “We have risked our lives and worked during the Covid-19 period, but the government is not paying us.
• This is wrong,” said 48-year-old ASHA worker Sushila Devi, mother of three. By August 2021, around 6,000 women in Delhi were not paid monthly incentives since April for visiting Covid-19 patients under home isolation.
• Non-payment of dues led to multiple protests by ASHA workers across the country. ASHA workers from Haryana, Delhi and Punjab protested near the Parliament in March 2022, alongside Anganwadi and mid-day meal workers, to raise incentives.
• In Tamil Nadu, ASHA workers staged a demonstration in April to draw the government’s attention to their demands.
• They have been demanding regularisation of jobs and a consolidated monthly pay of ₹18,000.
• In May, hundreds of ASHA workers gathered in Bengaluru’s Freedom Park to demand a fix for a web portal that is crucial to their payments.
• Women selected to be ASHA workers undergo a series of training programmes that enables them to fulfil their roles as the leader of community participation in community health programmes at village level.
• ASHA workers are responsible for promoting nutrition, basic sanitation and hygiene practices, healthy living and working conditions, awareness of existing health services, and the need for timely utilisation of health and family welfare services within their communities.
• They are also provided with a drug kit to perform primary healthcare functions – ASHA workers are the first responders in situations where deprived sections of the population find it difficult to access healthcare services.
• Encouraging women to give birth under safe conditions in hospitals and medical centres is another important responsibility shouldered by ASHA workers.
• Members of the local village community can access basic essential medical provisions like oral rehydration solution (ORS), iron-folic acid tablets, chloroquine, disposable delivery kits, oral pills and condoms from ASHA workers.

Who are ASHA facilitators?

• The ASHA facilitator is expected to be a mentor, guide, and counsellor to the ASHA. She/He is also expected to provide support, supervise, build capacity of the ASHA and monitor the progress of the individual ASHA in their given area.
• The general norm is to appoint one facilitator for every 20 ASHA.
• One of the main goals of the National Rural Health Mission (NRHM) is to offer a trained female community – based health activist, also known as an ASHA or Accredited Social Health Activist, to each and every village in the nation.
• The ASHA will be chosen from the village and will report to it. They will be trained to act as a link between both the society as well as the public health system. ASHA’s main components are as follows:
• ASHA should always primarily be a village woman who is married, widowed, or divorced, and preferably between the ages of 25 and 45.
• She ought to be a literate woman, with giving preference to someone who is educated up to the tenth grade, anywhere they are interested and in sufficient numbers. Unless no suitable person having these qualifications is available, can this be waived.
• Various local groups, self-help groups, Anganwadi Institutes, the Block Nodal officer, District Nodal officer, the village Health Committee, as well as the Gram Sabha will all be involved in the selection procedure.
• ASHA’s capacity building is viewed as a continual activity. ASHA would have to go through a sequence of training events in order to gain the essential knowledge, abilities, and confidence to fulfil her tasks.
• For encouraging universal immunisation, referrals and escort support for Reproductive & Child Health (RCH) and other health programs, as well as the building of domestic toilets, the ASHAs would earn performance-based incentives.
• Every ASHA is supposed to be a fountainhead of community involvement in public healthcare programs in her area, armed with information and a drug kit to provide first-contact healthcare.
• ASHA will be the primary point of contact for any health – related needs of the poor, particularly women and the children, who have difficulty accessing health care services.
• ASHA will operate as a community health activist, raising awareness about health as well as its socioeconomic factors and mobilising the community to support local health strategy and enhanced adoption and accountability of existing health care services.
• She would foster healthy habits and give a minimal package of curative care as necessary and practicable for that level, as well as timely referrals.
• ASHA will give community members with knowledge on health determinants like nutrition, basic sanitation and sanitary practices, healthy living and working environments, information on the current healthcare system, and the importance of using health and family welfare facilities on a timely basis.
• She would also counsel women on topics such as birth preparation, the importance of a safe delivery, breast-feeding as well as supplementary feeding, immunisation, contraceptive methods, and the mitigation of common infections such as Reproductive Tract Infections/Sexually Transmitted Infections (RTIs/STIs), as well as child care.
• ASHA will motivate and inspire the community and make it easier for them to access health and health-related facilities like immunisation, Ante Natal Check-up (ANC), Post Natal Check-up, supplementary nutrition, hygiene, and other government provided services, which are available at Anganwadis/sub-centres/primary health centres.
• She would also serve as a depot older for vital provisions such as Oral Rehydration Therapy (ORS), Iron Folic Acid Tablets (IFA), chloroquine, Disposable Delivery Kits (DDK), Oral Contraceptive Pills and Condoms, and so on, which will be made accessible to all habitations.
• ASHA cannot operate without proper institutional backing at the village level, it is acknowledged.
• Women’s committees (such as self-help groups or women’s health committees), the Gram Panchayat’s village Health and Sanitation Committee, ancillary health workers, particularly ANMs and Anganwadi workers, as well as ASHA trainers and in – service periodic training would all be major sources of support for ASHA.

How Significantly do ASHA Workers Contribute to the Healthcare System of India?

• They create awareness about health determinants by providing information to the people about nutrition, basic sanitation & hygienic practices, healthy living and working conditions, etc.
• ASHA counsels women on birth preparedness, safe delivery’s importance, breastfeeding, contraception, immunization, child care and prevention of Reproductive Tract Infection/Sexually Transmitted Infection (RTIs/STIs).
• ASHA provides primary medical care for minor disorders like fever, diarrhoea and minor injuries.
• They also keep the sub-centres/primary health centres informed about births and deaths in their village and any disease outbreaks/unusual health concerns in the community.
• Married, widowed or divorced women from the village community who possess basic literacy skills are eligible to be trained as ASHA workers. In most cases, women from the village itself are selected as ASHA workers who operate within the local community.
• According to the guidelines laid down by the National Health Mission, these women are preferably between 25 and 45 years of age and preference is given to candidates who have qualified up to tenth standard.
• The education criteria is relaxed only if no qualified person is available.
• On an average, an ASHA worker earns around ₹6,000-10,000 per month, including monthly honorarium from the Central and State governments, and incentives.
• They receive performance-based incentives for promoting India’s universal immunisation programme, referral and escort services for the government’s Reproductive and Child Health (RCH) programme, and construction of household toilets.