A Well-Deserved Recognition for India’s ASHAs | Jos Chathukulam, Manasi Joseph

Abstract

At a time when India’s one million Accredited Social Health Activists (ASHAs), who were at the forefront to battle the COVID 19 crisis are facing humiliation, hostility and neglect from the government authorities have left them without recourse, the conferment of Global Health Leaders Award to these frontline health workers provide a ray of hope to these unsung warriors. Meanwhile, the Award alone will not put an end to the sad plight of these ASHAs as they have to overcome various challenges to emerge as a strong woman health workforce at the grassroots level. 

India’s one million Accredited Social Health Activists (ASHAs) were honoured with WHO Director General’s Global Health Leaders Award [1] by World Health Organization (WHO) on May 22, 2022. The ASHAs are the backbone of the fragile rural healthcare system in India. The Award comes at a time when millions of ASHAS, who served as COVID warriors are facing hostility and neglect from the government authorities. Around one million ASHAs offered their selfless service during the first and second wave of the COVID 19 and in their battle against the pandemic they had to face abuse, harassment as well as physical and mental assaults.  In April 2020, when the country was placed under pandemic induced lockdown and citizens were asked to stay inside their homes, it was the ASHAs who stepped out of the safety of their homes and catered to the needs of those who were battling with the infections and other illness in rural areas (Chathukulam and Joseph, 2022). But that was not an easy job, as these frontline health workers were attacked and manhandled by the people when they went to help them. For instance, on April 3, 2020, a 45-year-old ASHA was heckled and manhandled by a group of over 50 people while she was conducting a COVID 19 related health survey at Sadiq Nagar in Northeast Bengaluru (Times News Network, April 3, 2020). Then on April 24, 2020, an ASHA in Odisha was attacked for collecting details of people with COVID 19 symptoms in a containment zone in her village. The attack took place when she was on her way home and it was reported that the accused along with his family members entered her house forcibly and assaulted her and family (Mohanty, 2020).

The humiliation doesn’t end there. There have been reports that many ASHAs were forced to work without wearing PPE kits and masks owing to shortage of these safety items in the initial days. Many of them contracted the virus and a lot of them lost their lives to COVID 19. Though there are no reliable data there are some state wise statistics of the ASHAs who died due to COVID 19. For instance, in February 2022, it was revealed that around 150 ASHAs died in Andhra Pradesh due to the pandemic and ill-health (Srinivas, 2022). Then in February 2021, the Union Ministry of Health and Family Welfare revealed in Rajya Sabha that till January 2021, around 44 ASHAs died due to COVID 19 (The Print, February 3, 2021). However, some reports suggest that around 100 ASHAs died while performing COVID duties during the first wave of the pandemic and government has not paid compensation to the bereaved families (Purohit, 2021).

The working conditions of the ASHAs are also pathetic. They are made to work inordinately long hours and paid humiliatingly low wages and at times payments are irregular. Though the Union government had announced a bonus of 1000 rupees for COVID work, that was also not timely paid. Under the Union government’s Pradhan Mantri Garib Kalyan Package Insurance Scheme [2], a comprehensive personal accident cover of Rs. 50 lakh was announced for 22.12 healthcare providers including ASHAs who may have been in direct contact and care of COVID 19 patients and succumbed to death due to the infection. It has been reported that since the launch of the scheme, around 1905 claims of health workers who died while being deployed for COVID 19 related duties have been settled (Press Information Bureau, April 19, 2022) but it is not clear as to how many of those received the entitled amount were ASHAs.

A Brief Glimpse into the History of Accredited Social Health Activists: From Village Health Guides to Mitanins to ASHAs

In the 1970s, the Union government initially introduced Community Health Worker (CHW) scheme with the provision of providing health services at the doorsteps of villagers. In the 1980s such schemes came to be known as Community Health Volunteer and later as Village Health Guides (Strodel and Henry, 2019). The inspiration for the creation of the ASHAs in 2005 can be traced back to the community health volunteer programme called Mitanin by the Government of Chhattisgarh in 2002. 

The Mitanin (meaning female friend in local dialect) played a pivotal role in early detection of health-related problems and helped in improving overall community health status in Chhattisgarh (Chourasia et al, 2018) and this very same programme inspired the formation of the ASHAs as a component under National Health Mission (NHM) (Chourasia et al., 2018). While Anganwadi Workers (AWWs) under the Integrated Child Development Scheme (ICDS) are engaged in providing supplementary nutrition programmes, supplementary feeding and pre-school education, there have been concerns that the AWWs are finding it hard to coordinate all the activities simultaneously and this also forced the Union government to create a new group of community based health functionaries called ASHAs.

Under the NHM, it has been envisaged that every village in the country should have a trained health activist called ASHA and they will serve as an interface between the community and public health system and mobilizes the rural community to facilitate access to health services available at both the primary health centres and sub-centres at the village level. They are often the first port of call for health-related issues and concerns among the rural community. ASHAs work to provide maternal care and immunisation for children against vaccine-preventable diseases; community health care; treatment for hypertension and tuberculosis; and core areas of health promotion for nutrition, sanitation, and healthy living.

According to the NHM guidelines, an ASHA must primarily be a woman who is the resident of the village, preferably in the age group of 25-45. Regarding the educational qualification, the NHM guidelines specify that they should be a literate person with due preference in selection to those who have formal education up to Class 8 (minimum qualification) or Class 10. However, relaxations will be provided if no suitable person with prescribed qualification is available. With regard to the selection process of ASHAs, as per the NHM guidelines, District Health Society envisaged under National Rural Health Mission (NRHM) is required to oversee the process of selection of ASHAs and have to designate a District Nodal Officer, preferably a senior person from the health department and Block Medical Officers for the same. Meanwhile, the final selection of the ASHAs is made by the Gram Sabha based on the names shortlisted by the district and block officials. After the selection, the ASHAs have to undergo series of trainings to acquire the necessary knowledge, skills and confidence for performing the assigned roles. The capacity building of ASHAs are a continuous process, and while considering a range of functions and tasks to be performed, induction training has to be completed in 23 days spread over a period of 12 months, as per the NHM guidelines.

The Three ‘A’s: Anganwadi Workers, Auxiliary Nurse Midwife and Accredited Social Health Activists 

The ASHAs cannot function without adequate institutional support and here comes the significance of Anganwadi Workers (AWWs) and Auxiliary Nurse Midwives (ANMs). There is already a convergence to some extent between the ASHAs and AWWs and ANMs. For instance, to provide orientation on importance of nutritious food, personal hygiene, immunization, pregnancy care, antenatal check-up and institutional delivery, a Health Day has to be organized in an Anganwadi Centre once or twice in a month and for this initiative women and children from each village has to be mobilized and AWWs entrust these tasks to ASHAs and seek their assistance in conducting the programme. Then there is Village Health, Sanitation and Nutrition Day (VHSND) which has to be organized in every village once a month at the Anganwadi Centre and in urban areas it is known as Urban Health Sanitation and Nutrition Day (UNHSD). For organizing the VHSND, the ANMs, ASHAs and AWWs have to jointly work together for mobilizing girls, children, pregnant and lactating women for creating awareness and ensuring their participation in health check-ups and immunization. The ASHAs are also an integral part of the Village Health, Sanitation and Nutrition Committee (VHSNC) and they have to collaborate with panchayat functionaries, self-help groups (SHGs) as well as AWWs and ANMs while preparing a Village Health Plan. As per the NRHM guidelines ASHA has to be the member secretary and convenor of the committee. The AWWs and ANMs also act as resource persons for providing training to ASHAs.

What the 15th UFC Health Grant means for the ASHAs and other frontline health workers

In the light of the Health Grants amounting to Rs. 70, 051 crores allocated by the 15th Union Finance Commission (UFC) to strengthen the health care system at the grassroots level, especially to provide support for diagnostic infrastructure for the primary healthcare facilities including Sub Centres (SCs) and Primary Health Centres, the ASHAs, AWWs and ANMs can also leverage their roles (Chathukulam and Joseph, 2022). The 15th UFC has also recommended measures should be taken to assign a larger role for nursing professionals, and the concept of nurse practitioner, physician assistant, and nurse anaesthetist should be introduced for better utilisation of nursing professionals. The ASHAs, AWWs and ANMs should be given training to assist nurse practitioners. For instance, though Class 8 and Class 10 are the prescribed qualification meant for ASHAs, these days even those who have completed higher secondary education and graduates are working as ASHAs, ANMs and AWWs in some states. So, if these people are given training to become assistants to nurse practitioner in the PHCs and SCs, it would also open the doors for obtaining a decent income to these already underpaid frontline health workers.

Unionization and Politicization of ASHAs 

Due to the ill treatment received from authorities including the non-payment of various incentives entitled to them, the ASHAs across many states have now rallied under various political unions and associations to address their grievances and to submit their representations to the authorities.  A study by BehanBox [3] during the pandemic revealed that ASHAs in most states, except Andhra Pradesh, Kerala, Karnataka, Haryana, West Bengal and Sikkim, do not get a fixed honorarium. The ASHAs are entitled to receive an honorarium of Rs. 2000 a month set by the Union government, conditional on completing a set of core tasks including organising Village Health and Nutrition Days, convening Village Health, Sanitation and Nutrition Committee every month, updating household data every six months, maintaining a record of birth and deaths and preparing the list for child immunisation. However, the major complaint is about the non-payment of incentives and authorities not increasing wages for ASHAs from time to time. Though ASHAs are supposed to work for 2-3 hours a day according to the Parliamentary Committee on Empowerment of Women titled ‘Working Condition of ASHAs (2009-10), these days ASHAs work for more than eight hours a day and at times even more. All these injustices meted out to ASHAs have forced them to rally under unions, especially the Centre of Indian Trade Unions (CITU) to fight for their rights and payments. The CITU affiliated ASHA worker unions are functioning in states like Haryana, Andhra Pradesh, West Bengal, Kerala, Madhya Pradesh, Maharashtra, Assam, Telangana, Punjab, Uttar Pradesh, Uttarakhand and Tamil Nadu.  Similarly, there is All Indian United Trade Union Centre (AITUC) affiliated ASHA unions like Karnataka State ASHA Workers Association. There are also many state wise associations like Telangana Voluntary and Community Health Workers Association, Kerala ASHA Health Workers Association, Karnataka Rajya Samyukta ASHA Union. These associations and unions have at times helped the ASHAs, be it in the release of their denied honorariums and incentives. For instance, on May 24, 2021, around 42,000 ASHAs in Karnataka boycotted their duties in protest against pending honorarium for more than two months. Following the one-day strike, 17 out of the 31 districts in Karnataka released the pending honorariums to these ASHAs. In Karnataka, ASHAs are provided a fixed honorarium of Rs. 4000 a month by the state government under NHM. In Kerala also ASHAs had to conduct strikes and protest, for their honorarium to be increased to Rs.6000 from Rs. 1000 over the years.  They also get an incentive of Rs. 2000.

While protests and strikes by ASHAs are common in all states, only some of them had succeeded in meeting their demands. In the case of Kerala and Karnataka, both states have continuously topped the Devolution Index [4] and both have scored much higher than the national average in the cumulative Devolution Index as well as in terms of funds, functions and functionaries too these states have scored higher than the national average. There can be two inferences drawn from these (1). Even in states (Kerala and Karnataka) with better devolution at the grassroots level ASHAs do face problems. (2) In states like Kerala and Karnataka, these ASHAs are capable of meeting their demands.  While there is no conclusive evidence to suggest that state governments with better devolution index have good relations with ASHAs and those with poor devolution index have bad relations with ASHAs, it has been reported that conflicts are less in states that have better devolution index. The relationship shared between ASHAs and local governments has not been documented in the Devolution Index, it would be interesting to look into the relationship between the two.

Political parties also exploit the pathetic condition of the ASHAs for elections and election campaigns. The promise to hike the salary of ASHAs and better working conditions is part and parcel of state election manifestos. ASHAs are even deployed for conducting election surveys and other non-health related programmes. Since ASHAs too share a good rapport and bond with people at the grassroot level they are even fielded as candidates in local government elections and there have been many instances where they even got elected to Gram Panchayats.

Conclusion 

While the honour and recognition for ASHAs is a matter of pride for the country and the ASHAs in general, the problems of these frontline health workers don’t end there. Though ASHAs serve as a crucial interface between communities to access the public health system, they receive meagre salaries, possess limited legal rights and social security protection and above all minimal recognition from the communities they serve. Among the three ‘A’s, ASHAs are really in a vulnerable position (Lahariya, 2022) The empowerment of the ASHAs along with the AWWs and ANMs is the need of the hour and it can be done by increasing convergence between them. The institutions like NITI Aayog should incorporate the indicator of health care workers to rate the performance of ASHAs in the National Health Index and they should undertake serious studies to understand the ground realities and hardships of frontline health workers like ASHAs. The local governments should also come up with strategies to empower them. The ASHAs, AWWs and ANMs should come together under one umbrella and should emerge as a strong women health workforce.

(Authors: Jos Chathukulam is former Professor, Ramakrishna Hegde Chair on Decentralisation, Institute for Social and Economic Change, Bengaluru and currently the Director of Centre for Rural Management (CRM), Kottayam, Kerala. He can be contacted via joschathukulam[at]gmail.com; Manasi Joseph, Researcher, Centre for Rural Management (CRM), Kottayam, Kerala)

References

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