•  The World Health Organisation (WHO) has recognized the contribution of India’s 1 million Accredited Social Health Activists (ASHAs) during the Covid-19 pandemic.
• It is acknowledged that ASHAs facilitate linking households to health facilities, and play pivotal roles in house-to-house surveys, vaccination, public health and Reproductive and Child Health measures.
• 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. There have been agitations demanding employee status for ASHA workers.
• The idea of performance-based payments was never to pay them a paltry sum — the compensation was expected to be substantial.

• Despite the risks, health workers across the country monitored coronavirus patients, provided medicine kits, isolated patients and sometimes delivered food to those in quarantine.
• Their most critical roles were ensuring continued access to essential health services when hospitals ran out of beds and encouraging vaccination.
• Several women said they were beaten with sticks by angry villagers, who chased them away after rumors on social media that Covid vaccines had killed people or made them infertile.
• Public health care infrastructure remains vastly underfunded in India, with a shortage of more than 600,000 doctors and 2 million nurses, according to a report by the Center for Disease Dynamics, Economics & Policy, a research group based in Washington and New Delhi.
• India, a country of 1.4 billion people, has a poor track record when it comes to health care, particularly of women and children.
• Malnutrition is widespread; infant and maternal mortality rates are high. Causes include poverty, poor access to doctors in rural areas, resistance to modern medicine and a deep-rooted denial of rights for women.

• An accredited social health activist (ASHA) is a community health worker instituted by the Ministry of Health and Family Welfare (MoHFW) as a part of India's National Rural Health Mission (NRHM).
• The mission began in 2005 By Dr ANBUMANI RAMADOSS Health Minister of India ; full implementation was targeted for 2012. The idea behind the Accredited Social Health Activist (ASHA) is to connect the marginalized communities to the health care system.
• One of the key components of the National Rural Health Mission is to provide every village in the country with a trained female community health activist ASHA or Accredited Social Health Activist.
• Selected from the village itself and accountable to it, the ASHA will be trained to work as an interface between the community and the public health system.
• Following are the key components of ASHA :
• ASHA must primarily be a woman resident of the village married/ widowed/ divorced, preferably in the age group of 25 to 45 years.
• She should be a literate woman with due preference in selection to those who are qualified up to 10 standard wherever they are interested and available in good numbers. This may be relaxed only if no suitable person with this qualification is available.
• ASHA will be chosen through a rigorous process of selection involving various community groups, self-help groups, Anganwadi Institutions, the Block Nodal officer, District Nodal officer, the village Health Committee and the Gram Sabha.
• Capacity building of ASHA is being seen as a continuous process. ASHA will have to undergo series of training episodes to acquire the necessary knowledge, skills and confidence for performing her spelled out roles.
• The ASHAs will receive performance-based incentives for promoting universal immunization, referral and escort services for Reproductive & Child Health (RCH) and other healthcare programmes, and construction of household toilets.
• 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.
• 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.

• The ASHA programme was based on Chhattisgarh’s successful Mitanin programme, in which a Community Worker looks after 50 households. The ASHA was to be a local resident, looking after 200 households.
• The programme had a very robust thrust on the stage-wise development of capacity in selected areas of public health.
• Dr T Sundararaman and Dr Rajani Ved among others provided a lot of support to this process. 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.
• Important public policy and public management lessons emerge out of the successful experiment with Community Workers who were not the last rung of the government system — rather, they were of 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.
• Over 98 per cent 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.

• The ASHAs faced a range of challenges: Where to stay in a hospital? How to manage mobility? How to tackle safety issues? The solutions were found in a partnership among frontline workers, panchayat functionaries, and community workers.
• This process, along with the strengthening of the public infrastructure for health with flexible financing and innovations under the Health Mission and Health and Wellness Centres, led to increased footfall in government facilities. Accountability increased; there would be protests if a facility did not extend quality services.
• The Community Worker added value to this process. Incentives for institutional deliveries and the setting up of emergency ambulance services like 108, 102, etc. across most states built pressure on public institutions and improved the mobility of ASHAs.
• Overall, it created a new cadre of incrementally skilled local workers who were paid based on performance. The ASHAs were respected as they brought basic health services to the doorstep of households.
• There have been challenges with regard to the performance-based compensation. In many states, the payout is low, and often delayed.
• The original idea was never to deny the ASHA a compensation that could be even better than a salary — it was only to prevent “governmentalisation”, and promote “communitisation” by making her accountable to the people she served.
• There were serious debates in the Mission Steering Group, and the late Raghuvansh Prasad Singh made a very passionate plea for a fixed honorarium to ASHAs. Dr Abhay Bang and others wanted the community character to remain, and made an equally strong plea for skill and capacity development of Community Workers.
• Some states incentivised ASHAs to move up the human resource/ skilling ladder by becoming ANMs/ GNMs and even Staff Nurses after preferential admission to such courses.

• 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.
• They act as a bridge connecting marginalised communities with facilities such as primary health centres, sub-centres and district hospitals.
• The role of these community health volunteers under the National Rural Health Mission (NRHM) was first established in 2005.
• 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.

• 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.
• She will counsel women on birth preparedness, importance of safe delivery, breast-feeding and complementary feeding, immunization, contraception and prevention of common infections including Reproductive Tract Infection/Sexually Transmitted Infections (RTIs/STIs) and care of the young child.
• ASHA will mobilise the community and facilitate them in accessing health and health related services available at the Anganwadi/sub-centre/primary health centers, such as immunisation, Ante Natal Check-up (ANC), Post Natal Check-up supplementary nutrition, sanitation and other services being provided by the government.
• She will act as a depot older for essential provisions being made available to all habitations like Oral Rehydration Therapy (ORS), Iron Folic Acid Tablet(IFA), chloroquine, Disposable Delivery Kits (DDK), Oral Pills & Condoms, etc.
• At the village level it is recognised that ASHA cannot function without adequate institutional support. Women's committees (like self-help groups or women's health committees), village Health & Sanitation Committee of the Gram Panchayat, peripheral health workers especially ANMs and Anganwadi workers, and the trainers of ASHA and in-service periodic training would be a major source of support to ASHA.

• 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, with the largest workforces in states with high populations – Uttar Pradesh (1.63 lakh), Bihar (89,437), and Madhya Pradesh (77,531). Goa is the only state with no such workers, as per the latest National Health Mission data available from September 2019.

 Asha Network in Pandemic

•  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.
• “During the first year of the pandemic, when everyone was scared of the infection, we had to go door-to-door and check people for Covid-19 symptoms. Those who had fever or cough had to be tested. Then, we had to inform the authorities and help the people reach the quarantine centres.
• We also faced a lot of harassment because there was so much stigma about the infection that people did not want to let us in.
• Kavita Singh from Delhi, a former ASHA worker and a member of Scheme Workers Federation of India, added, “We had to go to households with confirmed Covid-19 cases and explain the quarantine procedure. We had to provide them with medicines and pulse-oximeters. All of this on top of our routine work.”
• With the vaccination drive for Covid-19 beginning in January last year, they have also been tasked with motivating people to get their shots and collect data on how many people are yet to get vaccinated.