Context: 

This article is based on the news “The women of ASHA: overworked, underpaid and on the edge of breakdown” which was published in the Hindu. A recent study investigating the life of ASHA workers brought out the despicable situation of ASHA workers being overworked, underpaid and on the edge of breakdown.

ASHA Workers: Accredited Social Health Activist

• ASHA workers were introduced as part of the National Rural Health Mission (NRHM) in 2005 to act as a bridge between the community and the health system.
  • It was later extended to urban settings with the introduction of the National Urban Health Mission in 2013.
• Central Component of NRHM: ASHA, an all-female cadre of community health workers is the central component of the NRHM, which was launched to address the health needs of the rural population, especially the vulnerable sections of society.
• Training and Collaboration: ASHA workers receive training from Anganwadi Workers (ANWs) and Auxiliary Nurse Midwife (ANM) to discharge their duties.
• Inspired by: Mitanins inspired the creation of the ASHA framework, recognising their pivotal role in community health initiatives.
  • In 2002, Chhattisgarh appointed women as community health workers, known as Mitanins, signifying care and support for their communities. 
  • Mitanins translates to ‘friends’. A friendship, between women, one with the promise of compassion.

Roles and Responsibilities of ASHA Workers

• Health Education and Awareness:

  • Health Activism: ASHA acts as health activists for the community by raising awareness of health and its social determinants.
  • Awareness and Information Dissemination: Creating awareness and providing information on determinants of health such as nutrition, basic sanitation, hygienic practices, etc.

• Counseling Support:

  • Maternal Health: They counsel women on birth preparedness, safe delivery practices, and postnatal care.
  • Child Health: They advise on breastfeeding, complementary feeding, immunization, and care of young children.
  • Family Planning: They guide on contraception, family planning, child spacing and prevention of common infections, including RTIs/STIs.

• Community Mobilization and Facilitation

  • Access to Health Services: Facilitating community access to health-related services like immunization, ANC, and PNC at local health centres.
  • Village Health Planning: Collaborating with the Village Health & Sanitation Committee to develop comprehensive village health plans.
  • Support and Escort Services: Assisting pregnant women and children to access medical treatment and admission to health facilities.

• Primary Medical Care

  • Minor Ailments: Providing primary care for minor health issues such as diarrhoea, fevers, and minor injuries.
  • Directly Observed Treatment Short-course (DOTS): Acting as a provider under the Revised National Tuberculosis Control Programme.

• Miscellaneous Roles

• • Reporting Role: Informing about births, deaths, and any unusual health problems or disease outbreaks in the community at the Sub-Centres/Primary Health Centre.
  • Sanitation Campaigns: Promoting the construction of household toilets under the Total Sanitation Campaign.
  • National Disease Control Programs: Rendering services under various national disease control programs.

Selection of ASHA Workers

• Population Coverage: One ASHA is typically selected per 1000 population, ensuring manageable coverage for each worker.
• Geographical Considerations: In tribal, hilly, and desert areas, the selection norm may be relaxed to one ASHA per habitation, considering geographical challenges.
• Phasing and Coverage
• • State-Level Planning:  States must outline district and block-wise plans for ASHA selection, aiming for structured implementation.
• Implementation Timeline: At least 40% of ASHAs should be selected and trained in the first year, with the remainder in the following two years.

Criteria For Selection- ASHA Workers

• Demographic Criteria: ASHA must be primarily a woman resident of the village ‘Married/Widow/Divorced’ and preferably in the age group of 25 to 45 yrs.
• Communication and Leadership: ASHA should have effective communication skills, and leadership qualities and be able to reach out to the community. 
• Educational Qualifications: She should be a literate woman with formal education up to Eighth Class. This may be relaxed only if no suitable person with this qualification is available.
• Representation from Disadvantaged Groups: Adequate representation from disadvantaged populations should be ensured to serve such groups better. 
• Flexibility to State Government: State Governments may modify these guidelines except the basic criteria of ASHA being a woman volunteer with minimum education up to VIII class and that she would be a resident of the village.

Challenges Faced by ASHA Workers in India

• Economic Challenges

  • Underpayment and Irregular Wages: ASHAs receive an honorarium and performance-based incentives. Even these benefits are irregular, leading to financial instability.
  • Out-of-Pocket Expenditures: They incur expenses for job-related logistics (e.g., travel, mobile data) without reimbursement which further strain their finances.
  • Primary Source of Family Income: In many cases, ASHAs are their families’ main income source. However, their family monthly incomes varied between ₹5,000 to ₹15,000.

• Gender-Based Discrimination

  • Triple Shift Burden: They balance household duties, childcare, and extensive community health responsibilities without adequate rest or nutrition. This puts them at risk of anaemia, malnutrition and non-communicable diseases.
  • Food and Sleep Deprivation: They take irregular meals and have insufficient sleep due to workload. Gendered food apportionment also results in small food portions. 
  • Gendered Expectations and Abuse: They face societal expectations and abuse within their roles. It includes harassment and assault with little to no redressal mechanisms.

• Occupational Hazards

  • Health Risks: They are vulnerable to malnutrition, anaemia, non-communicable diseases, and obesity due to poor eating habits and high stress.
  • Climate Change: They work in harsh weather conditions, without proper protective gear or adjustments in work timings. Climate change has further strained their work conditions. 
  • Lack of Formal Recognition: They are not officially recognised as workers, which affects their entitlement to occupational health and safety measures.

• Informal Employment Issues:

  • Casualization of Work: The informal nature of their job precludes them from social security measures, including health insurance.
  • Limited Professional Development: Educational limitations and reliance on app-based work without proper training marginalise them further.
  • Lack of Policy Support: Absence of structured policies to address their working conditions, rights, and welfare comprehensively.
  • Expansion of Work: The umbrella of work under ASHA has expanded. It started with maternal and child health, including vaccination follow-ups, data logging, learning palliative care, reporting domestic violence cases, providing mental health support, etc.

• Systemic Inequities:

• • Marginalization: ASHAs often come from marginalised communities, facing caste and gender hierarchies that impact their well-being and job efficacy.
  • Lack of Recognition and Support: Despite their crucial role in community health, there’s a systemic failure to acknowledge their contributions and provide adequate support.

Way Forward

• Formal Recognition and Fair Compensation: Recognizing ASHAs as formal healthcare workers and ensuring fair compensation and timely payment of wages.
• Social Security and Health Insurance: Extending full social security benefits and health insurance coverage to ASHA workers to safeguard their health and well-being.
• Professional Development and Support: Providing continuous training and professional development opportunities to enhance their skills and knowledge.
• Safety and Dignity: Ensuring a safe working environment and mechanisms for grievance redressal to protect them from harassment and abuse.
• Systematic Investment: Continual, systematic investment in the ASHA program is crucial for strengthening India’s public health system and achieving better health outcomes for women, children, and society.