The strongest link in India’s public health system, the Ashas are faced with several challenges. Their stories reveal some stark realities of the bureaucracy, corruption within the system and atrocities imposed by nurses, paramedics and senior medical staff working in the government sector By Raelene Kambli
In January 2018, Jamena Khatun — an Asha worker from the Assam’s Chikonmati village in Darrang district during her routine checkup identified that a four-year-old girl child, Nurjahan Begum was suffering from severe acute malnutrition (SAM). In a family of five siblings, Nurjahan’s parents working on daily wages were unaware of the condition. Due to lack of finances, the parents were unable to provide their kids with nutritious food and medicine. Moreover, the family was not willing to take help of the Kharupetia Nutrition Rehabilitation Center (NRC) of Darrang district as they lacked trust in the system.
In Assam, prevalence of under-nutrition is relatively high among under five children. The recent data from NFHS-4 (2015-16) reveals that almost one third (29.8 per cent) children under five years of age are under-weight, 36.4 per cent children are stunted and 17 per cent children are wasted with 6.2 per cent of children are severely wasted.
Darrang district records a high load of severe acute malnourished children and is identified as an National Nutrition Mission (NNM) plus Aspirational district in Assam. Among the whole under population (123840) of drawing district, the percentage of stunting, wasting and anaemia is 43.5 per cent, 19.2 per cent and 45.5 per cent respectively and severity is more among the social economically backward population. Though children with SAM are identified in different vulnerable pockets, it is very difficult for an ASHA to motivate the child to admit in the Nutritional Rehabilitation Centre.
In keeping with this, Jamena put all her efforts in trying to convince the parents to seek help at the NRC as well as began the child’s nutrition diet at home. However, since Jamena has limited resources, she couldn’t do much to improve the child’s medical condition. Jamena regularly visited the patient and continued to counsel the parents. When she realised that little Nurjahan had developed severe complications associated with SAM, she pursued help from Kshetrimayum Rojita Devi in order to convince Nurjahan’s parents.
Jamena and Devi’s relentless efforts finally won Nurjahan’s parent trust and the little child was taken to the Kharupetia Nutrition Rehabilitation Center. At the time of admission, Nurjahan’s condition was fatal. According to the NHM State Programme Manager, Dr Dipjyoti Deka, Nurjahan suffered from multiple complications. Weakness, apathetic, failure to thrive, conjunctival xerosis, fever and cough were a few to name.
After weeks of treatment, Nurjahan’s condition improved and now she is back with her family.
In this case, Jamena’s adherence to her duty, her conviction and efforts put to save the life of a little child is commendable. She is certainly the cause why Nurjahan survived and now lives a better life. Like Jamena, there are several Asha workers who have dedicated their lives in the service of the nation.
A survey conducted by the Ministry of Health and Family Welfare between 2005 and 2012 indicates that health outcomes after the introduction of the ASHA programme have improved phenomenally in India. As per the report, a significant decline has been achieved in IMR from 58 per 1000 live births in 2005 to 30 per 1000 live births in 2012. Five states achieved the target of less than 21 and 12 states were in the range of 30-40. Maternal Mortality Ratio (MMR) reduced to 100/100,000 in 2012 from 301 in 2001. This could be achieved due to promotion of more institutional deliveries by ASHA workers. All thanks to this inevitable force of India’s public health system, we have been successful in controlling and eradicating dreadful diseases such as polio. Over the years, there has been an increasing ownership of ASHAs within the health system. According to Dr Rajna Mishra, Senior Research Scientist & Project Lead, Public Health Foundation of India, “Asha workers are being valued as a key community resource for their facilitatory roles, their other two key roles in terms of activist/social mobiliser and community care provider is yet to be fully realised.” Furthermore, during a public gathering in September this year, Prime Minister Narendra Modi hailed the efforts put by the ASHA community in order to improve the delivery of health and nutritional services within the country. He also announced the doubling of routine incentive packages offered to the Asha workers by the union government to motivate them. In addition, all Asha workers and their helpers will be provided free insurance under the Pradhan Mantri Jeevan Joyti Bima Yogna and Prime Minister Suraksha Bima Yogna.
Having said that, despite the recognition received so far, their achievements are not equivalently rewarded. There are several road blocks that hampers the successful implementation of the Asha workers programmes.
Factors affecting the performance of Asha workers
Right from convincing and counselling people, to delays in incentive payments to harassment from senior medical staff at district level, Ashas in India are faced with several challenges which not only demotivate them but hampers the implementation of health programme. A research report published in 2015 in the Human Resource for Health journal cited various challenges faced by Ashas. The report based on a large study revealed that the selection of ASHAs is influenced by power structures and poor community sensitisation of the ASHA programme. This presents a major risk in the long run to the success and sustainability of this programme. Moreover, during our research, Express Healthcare found out that the primary health centres which ASHAs are linked are ill-equipped. At times, these health centres do not even have a gynaecologist. ASHAs therefore, experience adverse consequences in their ability to inspire trust and credibility in the community.
Statistics on Asha workers as of January 2017
In India, there are around 877535 ASHAs working under the National Health Mission Program (NHM) and 93 per cent of ASHAs are in position at the national level (as on January 2017; Update on ASHA Program, MoHFW, 2017). Of these, 498440 ASHAs are from high focus EAG states, 55189 from North East, 323093 from non-high focus states and 813 from the Union Territories (UTs).
34 out of 36 States/UTs are implementing ASHA programme under the National Urban Health Mission (NUHM). A total of 42,769 ASHAs (60per cent) have been selected in urban areas. As per the norms, there should be an ASHA for every village with a population of 1000. The average population being covered by each ASHA was 902 and varied from 880 in EAG states, 653 in North East and 980 in Non EAG states (as on January, 2017).
Dr Misra explains, “Issues related to low incentive payments, delay in payments and release of funds, and rates of attrition are a cause for concern. Even though time lag between the selection of ASHAs and their trainings has been an issue in some states. Problems relating to the availability and replenishment of drugs and equipment kits for ASHAs is another hurdle. The need to improving the quality of skills of ASHAs related to nutrition, counselling for family planning, recognition of danger signs of pregnancy, and first contact care for sick new-born and children were also being pointed out from some states (10th CRM Report). The success of the ASHAs also depends on the ‘triple AAA’ platform (ASHAs, AWWs and ANMs) for convergent planning and implementation of programmes between the health and the ICDS departments.”
Additionally, there are some ASHAs that have limited knowledge about their role as an ‘activist’. Apart from this, their stories reveal some stark realities of the bureaucracy, corruption within the system and atrocities imposed by nurses, paramedics and senior medical staff working in the government sector.
Role of Asha workers
For years together, Ashas have acted as an interface between the community and the public health system. They serve as the first port of call for any health related demands of deprived sections of the population, especially women and children who find it difficult to access health services. Empowered with knowledge and a drug kit to deliver first-contact healthcare, every ASHA is expected to be the fountainhead of community participation for public health programmes in her village. She receives performance based incentives for motivating women for institutional deliveries, promoting universal immunisation, referral and escort services for Reproductive & Child Health (RCH) and other healthcare programmes, and construction of household toilets. Besides, she is a promoter of good health practices and provides a minimum package of curative care services and ensures timely referral of cases. She is supported by other institutional support mechanisms such as women’s committees (Self-help groups or women’s health committees), village Health Sanitation and Nutrition Committees of the Gram Panchayat, peripheral health workers especially ANMs and Anganwadi workers, and the ASHA mentors.
Pramila Singh, an Asha worker from UP informs about the trails they have to undergo to ensure that good health in their community. “It has taken a lot many years for us to change the mindset of people, especially, women convincing them to have institutional deliveries. In our region, today, we have managed to increase institutional deliveries by around 60 per cent. This has helped in reducing MMR in our region. However, women struggle to get their cash benefits. The cash benefits take more than seven to eight months to reach the patients. At times, we have to help these patients financially in order to help them get nutritious food. We feel, after so much efforts put by us, we don’t get our incentives on time. It takes several months of us to get our incentives.”
While, Singh spoke to us, she also indicated of the ill-treatment done by nurses and paramedics at the health centres. “Usually, the women who seek help at the government’s health centres are extremely poor. Nurses many times are very rude to these patients. When the doctor is not around, the nurses and other medical staff really act rude. Moreover, we have a severe shortage of ambulance services and we have to bear with the ambulance attendant’s bad attitude.”
Similarly, Netrdipa Patil speaks about the situation in the Kolhapur region of Maharashtra. She is also part of the Asha workers union for the state of Maharashtra. She says that in Maharashtra there are around 65,000 Asha workers and they all have similar issues. In her region, Patil caters to around 30,000 people with only two ANM centres. Asha workers in her region also face with identical problems of harrassment by senior nursing staff. While speaking also she revealed some startling facts. “Apart from a very incentive package of approximately INR 1.50 or INR 2 for a patient survey which is again delayed for six to seven months, we are faced with a severe shortage of medicine since the year 2009. Calcium tablets, Paracetamol, iron supplements, cough medicines which is a regular demand are in scarcity for a long time. We have met the Health Secretary and the Health Commissioner several times in these years. But as officers change, rules and methods of work also change. Recently, we met the current Health Secretary of Maharashtra, who announced that the government has finally come will a solution to ensure that medicines will not be in short supply. But, we are unsure of its implementation.”
The ASHA usually fulfils 10 critical functions for the community where she operates as follows
- Create awareness and provide information to community
- Counsel mothers on birth preparedness, safe delivery, feeding practices, immunisation, family planning, RTI, etc
- Facilitate community access to health care and health facilities
- Accompany pregnant women and children to health facility
- Provide care for minor ailments
- Act as depot holder for ORS, IFA, DDK, Oral pills, condoms
- Provider of DOTS
- Newborn care and treatment of childhood illness (IMNCI)
- Inform birth and deaths, disease outbreaks
- Construction of Toilets for TSC (Total Sanitation Campaign) -Not included in UP state policy for ASHAs
Patil also informed of the health surveys that they have recently conducted in the Kolhapur district that recorded 19,000 cancer cases with the region. She informed that the government officials indicated them of the survey, but no training is been provided to Asha workers to conduct such tests. Further on, the launch of the Ayushman Bharat scheme has brought more work for the Ashas as they will act as a key link with a responsibility on educating and convincing people to enroll themselves under this scheme. “People will be offered a cover of INR 5 lakh but we will get an incentive of INR 5 per registration only,” she lamented.
While Singh and Patil are agitated with situation in their states, Pinky Tyagi from the Haridwar district, Uttarakhand and Jamena Khatun have been very contented in the facilities they receive in their region. Tyagi says that their payments have been on time, patients and doctors are cooperative and facilities at the health centres and hospitals are good. She says that more training and collaboration from the government will improve their work and bring in more efficiencies in the system.
Patil also believes that more training and proper planning of any new schemes is a must in order to increase competence among Asha workers. “The focus of our health programmes should be directed towards preventive care rather than looking to cure illnesses. If we want to build a strong and healthy nation, we should encourage a healthy lifestyle. Our Asha workers, therefore need to be uplifted and educated to take on better roles as health advisers”, she recommended.
In the same light, Indraprastha Institute of Information Technology Delhi (IIIT- Delhi) has come up with a project Sanghosti that is targeted at building a low cost technology-enabled solution for empowering ASHA workers. It is a research project which aims to strengthen an ASHA work by educating her though innovative mobile learning platforms. Last June, IIIT-D conducted a field deployment programme in Haryana to train 20 ASHA workers on Home-Based Newborn Care with the help of PGIMER Institute (Chandigarh) and a NGO SWACH (Panchkula, Haryana).
During their research, Sanghosti found significant positive results in terms of both imparting knowledge to the ASHA workers and in providing direct benefits to the corresponding target families. The study highlighted the potential of Sanghosti to establish a complementary approach to the traditional training mechanisms. IIIT-D is continuing their research and development on advanced features to make Sanghosti better.
Solutions like these, can be of great help in empowering the Ashas and facilitating them to realise their true potential as a health activists. In future, the government with needs to further increase the incentive packages for Ashas in order to motivate them. Also, look at better governance of the Asha programmes and take serious action on cases of harassment.