A case for community-oriented health services

News: Recently, India’s Accredited Social Health Activists (ASHA) received the WHO’s Global Health Leaders Awards 2022 in recognition of their work during the COVID-19 pandemic as well as for serving as a link between communities and health systems.

Contributions of the ASHA  workers

They have led to increased access to primary health-care services; i.e., maternal and child health including immunisation and treatment for hypertension, diabetes and tuberculosis, etc.

Served both rural, urban populations and difficult-to-reach habitations.

Worked to make India polio free, increasing routine immunisation coverage; reducing maternal mortality; improving new-born survival and in greater access to treatment for common illnesses.

They have become pivotal to nearly every health initiative at the community level, and are integral to demand side interventions for health services in India.

Genesis of the programme

Inspiration: (1) 1975 WHO monograph titled ‘Health by the people’, (2) 1978 International conference on primary health care in Alma Ata, and (3) 2002 Mitanin initiative of Chhattisgarh in which all-female volunteers were available for every 50 households and 250 people.

Initially, India launched the Community health volunteer’s scheme. But it failed because of lack of development of a community connection and lack of political will.

Launch of the programme

It was launched in 2005-06 as part of the National Rural Health Mission. Later it was extended to urban settings after the launch of the National Urban Health Mission in 2013.

Features of the ASHA Programme

One, the key village stakeholders are involved in the process of ASHA selection. This ensures community ownership for the initiatives and forging a partnership.

Two, ASHAs came from the same village where they worked. This ensured familiarity, better community connect and acceptance.

Three, the phrase activist was joined in their name to reflect that they were/are the community’s representative in the health system, and not the lowest-rung government functionary in the community.

Four, they were called volunteers to avoid a slow process for government recruitment and to include elements of the performance-based incentives and some accountability.

Functioning of the Programme

Each of the women-only volunteers work with a population of nearly 1,000 people in rural and 2,000 people in urban areas.

ASHAs coordinate things within villages and with the health system, with the help of Anganwadi workers (AWW), Auxiliary Nurse Midwife (ANM), panchayat representatives and influential community members at the village level. The A-A-A: ASHA, AWW and ANM, act as three frontline functionaries at the village level and form the all-women partnership to provide the primary health-care services to the community.

Platforms such as village health, sanitation and nutrition committees were created, for coordination and service delivery.

What are the challenges?

The ASHA volunteers have dissatisfaction. There are regular agitations and protests by ASHAs in many States of India.

Among the A-A-A, ASHAs do not have a fixed salary. The total payment including performance-based incentives remain low and often delayed. They don’t have opportunities for career progression.

Way Forward

The global recognition should be used as an opportunity to review and further strengthen the ASHA programme. This will make a stronger and community-oriented primary health-care system.

Indian States need to develop mechanisms for higher remuneration for ASHA workers.

An in-built institutional mechanism should be created for their capacity-building and providing avenues for career progression. For example, they can move to cadres such as ANM, public health nurse and community health officers.

The ASHAs and their family should be given the benefits of the social sector services like health insurance.

An independent and external review of the programme needs to be given urgent and priority consideration.

Many of the temporary posts in the National Health Mission can be put to regularization. In fact, ASHAs can be made permanent government employees.

Source: The post is based on an article “A case for community-oriented health services” published in the “The Hindu” on 02nd June 2022.

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