ASHA

India's ASHA program was initiated in 2005-06 and it is the world's largest community volunteer program with 9.83 lakh ASHAs across India. ASHAs are women aged between 25-45 and they serve as vital community health workers. They create awareness on health practices, counsel on immunization and family planning, and provide basic medical care. ASHAs played a crucial role during the COVID-19 pandemic. Despite their significant contributions, they face challenges like job insecurity, discrimination, and gender issues. This highlights the need for better remuneration, health benefits, and permanent positions. The government must ensure their welfare and recognition.

The Union Government has decided to include ASHAs and Anganwadi workers into the free cover for health treatment under Ayushman Bharat(AB) Scheme by March 1 this year. According to the Health Ministry's annual ASHA update for 2020-21, India has 9.83 lakh ASHAs deployed across 35 States and UTs (excluding Goa and Chandigarh), making it the largest community volunteer program globally. It was initiated in 2005-06 under the National Rural Health Mission, and initially launched in rural areas and later expanded to urban settings through the National Urban Health Mission in 2013. The ASHA program drew inspiration from Chhattisgarh's successful Mitanin initiative, where a Community Worker attends to 50 households.

ASHA are volunteers workers from within the community and are trained to provide information and assist people in accessing the benefits of various healthcare schemes of the government. The ASHA program started as an important part of community efforts and is now the biggest community health worker initiative globally. The ASHA scheme is working in all states and union territories except Goa. States have to make sure there's at least one ASHA worker for every 1000 people.

The requirements to be a ASHAs worker are:

• An ASHA should be a woman living in the village and must be married, widowed, or divorced, preferably aged between 25 and 45 years.
• She should be a literate woman, with a preference for those who have completed up to the 10th standard (formal education up to Class 8). This requirement can be relaxed only if no suitable person with this level of qualification is available.
• In urban areas, an ASHA should be a woman residing in "slum/vulnerable clusters" and belonging to the specific vulnerable group identified by the City/District Health Society for the selection of ASHA. Additionally, she must possess good communication and leadership skills.

ASHAs are compensated by:

• The monthly earnings of an ASHA worker range from Rs 2,000 to Rs 7,000 on average, and this amount varies depending on the state. They are not paid a regular salary as they work on “honorary” basis.
• She also qualifies for incentives provided under various national health programs.
• She can also earn income through the social marketing of specific healthcare products such as condoms, sanitary napkins, and more.

• Community Awareness: They create awareness and provide information about nutrition, basic sanitation, and hygiene practices.
• Women's Health Counseling: They counsel women on various aspects including immunization, contraception, prevention of infectious diseases, and birth preparedness.
• Communication Bridge: They act as a key communicator between the healthcare system and the rural population.
• Facilitate access: They mobilize the community and facilitate their access to health services such as sanitation, ante-natal and post-natal checkups.
• Health Planning: They collaborate with the Village Health & Sanitation Committee of the Gram Panchayat to develop a comprehensive village health plan.
• Demographic Record Keeping: They inform the community about births and deaths, and assist in keeping and collecting demographic records.
• Primary Medical Care: They also provide primary medical care for minor ailments like fever, diarrhea, and first aid.
• Family Planning Advocacy: They encourage and motivate target couples in the community for family planning.

• ASHAs were awarded the Global Health Leaders Award in 2022 by World Health Organisation.
• ASHAs have played a remarkable role in enhancing access to essential primary healthcare services, particularly in areas related to maternal and child health as well as immunization.
• During the Covid-19 pandemic, ASHA workers performed the following functions:
  • Conducting screenings for Covid-19 symptoms among individuals
  • Notifying authorities and assisting individuals in reaching quarantine centers
  • Offering detailed explanations of the quarantine procedures to the affected individuals
  • Distributing necessary medications to patients.

• Job Insecurity: ASHA workers are not officially considered government employees and are designated as "honorary/volunteer," lacking the stability of permanent employment.
• Salary Disparity: Among the rural 3As (Anganwadi Workers, Auxiliary Nurse Midwife, and ASHA), ASHAs are the only group without a fixed salary or avenues for career advancement.
• Resource Challenges: ASHAs face difficulties in accessing information and resources, especially in providing healthcare services during and after conflicts.
• Caste Discrimination: ASHA workers encounter barriers, including restrictions from entering homes of higher social caste residents.
• Domestic Struggles: Balancing the work and domestic responsibilities creates conflicts for ASHA workers and leads to potential issues such as divorce threats.
• Gender Bias: ASHA workers endure derogatory comments and discriminatory behavior from community members based on their gender.

Despite their substantial contributions in improving the health outcomes, the ASHAs lack adequate remuneration, health benefits, and permanent positions. Government has the responsibility to ensure their well-being, safety, and security. Government’s move to include ASHA workers under the Ayushman Bharat Health Scheme is a good step in this direction. There is a need for a mentorship program initiative that can offer emotional support and guidance and empower ASHAs to navigate the complexities of the health system. There is also a need for addressing caste and gender discrimination and ensuring that ASHAs are treated with dignity. Establishing open channels of communication between ASHAs and their supervisors will also foster constructive dialogue and collaboration. It is imperative to promote widespread community recognition of ASHAs' contributions and foster a sense of pride and appreciation towards ASHAs.