Using digital tools to train, connect and empower ASHAs is paramount to improve efficiencies in India’s primary health system By Prathiba Raju
Clad in a pink saree, 34-year-old Phool Kumari Devi, in Block Oranjhi from Ranchi district, 30-year-old Bharati from Uttarakhand and 40-year-old Geeta Verma from Himachal Pradesh, Mandi district are Accredited Social Health Activist (ASHAs) who work in difficult terrains across the country providing basic healthcare facilities, assisting expectant mothers and women on reproductive health, amid others. Looked upon as guarding angels, they mostly work without their magic wands – without the help of digital innovations and solutions. Acknowledging and addressing Devis and Bharatis as digital health assistants is the need of the hour.
ASHAs – Sheros of primary healthcare
ASHAs inclusion as a Community Health worker in India’s healthcare domain dates back to the National Rural Health Mission (NRHM) introduced in 2015 wherein they were responsible to motivate women for institutional deliveries, bring children to immunisation clinics, encourage family planning – both terminal and temporary methods, treat basic illness and injury with first aid, keep demographic records and improve village sanitation, among others. Today, nearly 900,000 ASHAs, are mostly the first point of contact in the health system, play a critical role in the early diagnosis of diseases and their prevention. They have played a pivotal role in bringing down infant mortality rate (IMR) from over 58 deaths per 1000 live births in 2005 — when ASHA was launched under NRHM — to 33 deaths per 1000 live births in 2017. Maternal mortality ratio (MMR) was 254 maternal deaths per 1,00, 000 live births during 2004-06 which has declined to 130 maternal deaths per 1,00,000 live births in 2014-16.
Phool Kumari Devi, a farmer and ASHA worker, informs that her work demands 24×7 commitment and at times she has no time to eat her meals and has to fulfill her duties on an empty stomach.
“Though my work is towards promoting healthy behaviours in my community, it leaves me with little time for my own family and children. During the sowing and harvesting season, I too need to balance time between my work and farming. Apart from that, when sometimes untoward incidents happen due to various factors like traditional mindset of the community or lack of awareness, or delay in accessing health services as I am a direct contact for my community members, I face criticism. This affects me for some days, but due to the motivation of my department and well wishers, I try to work even harder. If we have digital help like mobile apps, it will help us to ease our work load,” informed Devi. When it comes to Primary Healthcare Centres (PHCs), ASHAs can be a potential digital disruptor. Since there is a scarcity of doctors and paramedics, digital empowerment to these sahiyas can transform the grass-root healthcare service, inform experts.
Train, connect and empower
Training, connecting and empowering ASHAs by leveraging technology is a necessity at the moment, and the key to better healthcare. If last-mile health can be digitally empowered, ASHAs can bring in a sea change in primary and tertiary care.
Informing that ASHAs are only empowered to some extent, Dr Rajna Mishra, Senior Research Scientist, Public Health Foundation of India (PHFI) said, “Though not completely, ASHAs are digitally empowered to some extent. The spread of mobile technology and its priority in healthcare has created a new field of eHealth i.e., “mHealth”, which has the capability to provide individually-tailored and customised services to underserved people. Mobile phone as a media is now comparable to the popular media like radio and television which have been used for spreading healthcare awareness messages for decades. mHealth could be used by ASHAs, especially for point-of-care services, provision of health information, counselling, drug adherence, data collection and monitoring. Besides, during home visits for identification and referral of cases, in case ASHAs face problems, digital empowerment would be ideal, so that they could get an expert opinion which would help them in indecisive situations. However, it is to be noted that the capacities of ASHAs have to be built and they need to be trained on the digital health tools.”
Speaking about one such project, Ritika Pandey, Project Head, Digital Green, said, “It is a United States Agency for International Development (USAID)-funded project where ASHA workers are trained on community-based video production as well as dissemination skills. Videos are locally produced by the community members showcasing good practices in health, nutrition and family planning targeting local myths, taboos, misconceptions and practices around maternal and child health and family planning. This video-based approach has increased the effectiveness of behavioural communications by ASHA, but it also brings along high level of efficacy and efficiency. In many areas, ASHAs were able to reach hardly 10- 20 households in a month. Now, with video-based approach, they are able to cover 300- 400 households in a month. In areas where population distribution is highly scattered, video dissemination approach has been highly helpful as now they can cater to 20- 30 women in one screening session. Video dissemination has also proved helpful in mobilising women. It works as a pull factor for generating demand among women and other community members to attend the screening and increased attendance on these platforms. Many state governments have been showing their interest in community video approach by allocating funds for the same.”
Devi, an ASHA worker who has participated in one such project, informed that Pico projectors have helped her in mobilising the community members and the practices are easily understood by them leading to an increase in uptake of practice.
“Earlier, I conducted meetings in which I had to verbally explain about health, nutrition and family planning topics to my community. Sometimes, I used to forget to communicate the entire information. However, after I was trained by NHM and Digital Green using the projector, I started disseminating videos on a variety of topics like care during pregnancy, IFA, ANC, complementary feeding, washing hands, family planning. The entire information gets delivered to all community members effectively. Project SAMVAD has enabled the community members to carry discussions about health and family planning issues, as videos depict the issues of our locality, made in the local language featuring the local community members,” she added.
Many ASHA workers inform that digital projects are run by few NGOs are temporary. Also, certain projects that are led by National Health Mission (NHM) or state governments associated with NGOs, mostly end abruptly, or within a year. Thus, they are unable to understand or benefit from it.
Bharati, a 31-year-old ASHA worker from Uttarakhand, said, “Many mobile apps and digital initiatives by the state or central government are not reaching us. For example, we attend few digital programmes and projects organised by NGOs that do not sustain. We do not gain much out of such programmes.”
Observations from the field reveal that qualified ASHAs perform well. However, older ASHAs and less educated ones seem to be facing problems with digital tools, including Android-based mobile phones. ‘ASHA SOFT’ has been used in the state of Rajasthan in which the work done by ASHAs is captured including her visits, payments/incentives to ensure that it is done promptly in a transparent and easy manner. Evidence suggests that this has reduced the time taken for payment of ASHA incentives in the state. ‘ASHA SOFT’ is also linked to the existing PCTS – Pregnancy, Child Tracking and Health Services Management System which is an online software used as an effective planning and management tool by Medical, Health and Family Welfare Department, Government of Rajasthan. The system maintains online data of more than 13,000 government health institutions in the state. mSakhi project in Maharashtra aims to collect data, monitor and evaluate the ante-natal and post-natal healthcare and nutrition of infants up to six months.
In 2016, the Government of India launched four mHealth initiatives – Kilkari, Mobile Academy, M-Cessation and TB Missed Call under its Digital India programme. Under the Kilkari programme, a woman receives free, weekly and
time appropriate audio messages about pregnancy, child birth and child care from second trimester of pregnancy till
the child becomes one-year-old. This has been launched in Odisha, Jharkhand, Uttar Pradesh and some parts
of Madhya Pradesh and Rajasthan.
“Apart from the apps which have already been initiated in various government programmes which is run only in certain states, Mobiles apps such as a ASHA Reporting App, Home Based Post Natal Care App, Home Based Infant and Young Child Care App, Apps for Communication and Counselling should be available pan-India for a more cohesive IT system for strengthening ASHAs,” informed Mishra.
“Many here have mobile phones, including me, but they are not Android based and at times we are not able to access the mobile Apps. Even if we have smartphones, due to power and connectivity issues and high Internet package rates, we unable to access these apps. Many ASHAs in Uttarakhand and Uttar Pradesh are still maintaining the 94-column register, which involves cumbersome paperwork,” Bharati pointed out.
As per industry experts, with implementation of Ayushman Bharat – Prime Minister -Jan Arogya Yojana and Health Wellness Centres (HWC) a conscious attempt by the central government to address healthcare issue holistically, enabling frontline workers, particularly ASHAs as digital health assistants is crucial.
Real-time data sharing by ASHAs to the HWC will bring in a sea change into the healthcare delivery system and it is essential. There are various innovative mobile technologies used in different states and ASHAs are trained to use them, but they are fragmented, which needs to be addressed.
“The central government should envisage a strong IT platform or model which would integrate the data capture from the registration of the patient to tracking service delivery and measuring outcomes. The model should implement a digital format of the family health records which is currently in paper format. The key role of implementing individual health records at the village level will be through ASHAs. This can be implemented only in a phased manner taking into consideration human resource capacity, connectivity issues and resource availability,” said Dr Krishna Reddy, Country Director, ACCESS Health India.
Reddy also informed that ASHA workers are the connecting link between the community and primary healthcare and have a significant role to improve overall community health outcomes. Implementation of an ASHA registry has become critically important to empower and appreciate ASHAs for the work they are doing for the society.
“Digital health has already envisaged design, development and implementation of a National Frontline Health Worker Registry which will help in identifying every ASHA uniquely and will assign a unique identifier. ASHAs’ health worker ID will be seeded with Aadhaar number or any alternate government ID and will help in authenticating the activities performed by them and further training will empower them. This unique identifier will facilitate interlinking of different programme-specific IDs and will streamline the incentivisation and payment workflow for them. It will also help to track these sahiyas’ complete workload life-cycle and will facilitate creation of dashboards and MIS reports, that will reflect the workload analysis on the basis of the real data collected for any particular ASHA worker,” added Reddy.
As we debate on how can we bring more digital power to the Devis, Bharatis and Geetas of our country, these unsung sheros continue to relentlessly serve the nation with their undeterred spirit of caregiving. With this hope that in future we will see more empowerment among ASHA workers, the government must also provide them with better pay scales, education and other facilities.