A case for community-oriented health services

India’s one lakh Accredited Social Health Activist (ASHA) volunteers have received arguably the greatest international recognition As of the World Health Organization’s Global Health Leaders Awards 2022. Asha was among the six laureates announced at the 75th World Health Assembly in Geneva. The World Health Organization (WHO) award is for the work done by ASHA volunteers during the COVID-19 pandemic, as well as for serving as a link between communities and health systems.

It is important to note that even before the COVID-19 pandemic, ASHA has made extraordinary contributions to increasing access to primary health care services; i.e. maternal and child health including immunization for both rural and urban population and treatment of hypertension, diabetes and tuberculosis, etc., with special focus on remote areas. Over the years, ASHA has played an outstanding role in making India polio free, increasing routine immunization coverage; reduction in maternal mortality; Improving neonatal survival and greater access to treatment for common diseases.

Origin of program

India launched the ASHA program in 2005-06 as part of the National Rural Health Mission. Initially in rural areas it was also extended to urban settings with the launch of National Urban Health Mission in 2013. Each of these women-only volunteers works with a population of about 1,000 people in rural areas and 2,000 people in urban areas with flexibility for local adjustment. The basic objective of the ASHA program is to build the capacity of the community members to take care of their health and be a participant in health services.

The ASHA program was inspired by lessons learned from two previous initiatives: one in the late 1970s and the other in the early 2000s. In 1975, a WHO monograph titled ‘Health by the People’ and then in 1978, an international conference on primary health care in Alma Ata (in the then USSR and now Kazakhstan) emphasized countries recruiting primary health workers. Health care services that were participatory and people-centred. Soon after, several countries started community health worker programs under different names. In India, they were called community health volunteers. However, within a few years of implementation, the Community Health Volunteer Plan faced several constraints and evaluations indicated that a major reason for sub-optimal success was the failure of community health volunteers to build community engagement (indeed, People did not consider them different from the existing government employees). Before the community health volunteer program was forgotten, a lack of political will was another factor behind the scaling up.

The biggest inspiration for designing the ASHA program was Chhattisgarh’s Mitanin (meaning ‘a lady friend in Chhattisgarhi’) initiative, which started in May 2002. Mitanin was an all-female volunteer available for every 50 households and 250 people. , Public health experts and civil society organizations who had firsthand experience in developing and designing the Mitanin program were also involved in developing the ASHA program.

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The ASHA program was well thought out from the outset and consulted with public health experts and community-based organizations. One, ASHA selection involved key village stakeholders to ensure community ownership for the initiative and form a partnership. Two, ASHAs coming from the same village where they worked, aimed to ensure familiarity, better community connectivity and acceptance. Third, the idea of ​​naming workers after them was to show that they were the community’s representative in the health system, not the lowest-ranking government official in the community (as was the perception with the then-Community Health Volunteer, a few decades ago). . Fourth, calling them volunteers was partly to avoid a painfully slow process for government recruitment and to give them the opportunity to implement performance-based incentives in the hope that this approach would bring some accountability. One practical aspect was that performance-based incentives were being introduced in health services for the first time on such a scale. The thinking was that it would be easier to implement performance-based incentives under the new program and new workforce rather than existing government employees.

Since the launch of the ASHA initiative, numerous reviews and field assessments have documented the successes and learnings. There is an unusual consensus of public health experts that ASHAs have become vital to almost every health initiative at the community level and are integral to the demand for interventions for health services in India.

a partnership, obstacles

However, the program has its own set of challenges, which have been addressed in a consistent and timely manner, through sustained political will and by creating institutional mechanisms, i.e. community actions for health and ASHAs counseling groups. For example, when newly recruited ASHAs struggle to find their way and coordinate with and within villages and with the health system, their engagement with two existing health and nutrition system workers – Anganwadi Worker (AWW) and Auxiliary Nurse Facilitated along with Midwife (ANM) as well as Panchayat representatives and influential community members at village level. This resulted in an all-women partnership, or AAA, of three frontline workers at the village level: ASHAs, Anganwadi workers and ANMs, working together to facilitate health and nutrition service delivery to the community. For coordination and service delivery, forums like Village Health, Sanitation and Nutrition Committees were created. In the process, the trio became a well-known and respected face of primary health care services for the community; Their working together ensured greater internal accountability. In 2022, it is difficult to imagine how India would have responded to the COVID-19 pandemic had it not been for ASHA, Anganwadi workers and ANMs.

Nevertheless, there are ongoing challenges that need to be addressed urgently. In AAA, Asha is the only one who does not have a fixed salary; They do not have the opportunity to advance in their career. Although performance-based incentives are supplemented by a fixed amount in some Indian states, the total payout remains low and is often delayed. These issues have resulted in discontent, regular agitations and protests by ASHAs in many states of India.

The global recognition for ASHA should be used as an opportunity to revisit the program from a solution perspective. First, Indian states need to develop mechanisms for higher remuneration for ASHA. Performance-based incentives should not be interpreted to mean that ASHAs – no matter how much and how hard they work – need to be paid the lowest of all healthcare workers. If they work more, the system should allow them to be paid even more than regular government employees.

Second, the time has come to create in-built institutional mechanisms for capacity building and career advancement for ASHAs in other cadres such as ANMs, Public Health Nurses and Community Health Officers. Some Indian states have started such initiatives but these are on a smaller scale and in the initial stages.

external review needed

Third, consideration should be given to expanding the benefits of social sector services, including health insurance (for ASHAs and their families). The possibility of automatic entitlement of ASHA and access to a wide range of social welfare schemes needs to be institutionalised.

Fourth, while the ASHA program has benefited from several internal and regular reviews by the government, an independent and external review of the program needs immediate and priority consideration.

Fifth, there are arguments for regularizing several temporary posts in the National Health Mission and making ASHA permanent government employees. Considering the widespread shortage of workforce in the workforce at all levels, and in the primary health care system in India, and the continuing need for what ASHA is doing, this is a policy option to be considered seriously. needed. At the same time, it needs to be acknowledged that the specific jobs at the village level, which one expects, may not be ideally suited for a permanent post. However, finding the middle path will not be too difficult.

The WHO Award for ASHA Volunteers is a proud moment and also a recognition of every health worker working for the poor and underprivileged in India. It is an acknowledgment of the role and relevance of people-centred primary health care services. This is a reminder and an opportunity to further strengthen the ASHA program for a robust and community-oriented primary health care system, which will also prepare India for future pandemics and pandemics.

Dr. Chandrakant Laharia is a Primary Care Physician and Public Health Specialist. He has been involved in the implementation of the National (Rural) Health Mission in India since its inception. E-mail: c.lahariya@gmail.com