ASHA: Frontline Workers Sidelined by Authorities in COVID-19

An accredited social health activist, commonly referred to as ASHA; refers to a community health worker the Ministry of Health and Family Welfare instituted as a part of the National Rural Health Mission (NRHM). One of the key components of the National Rural Health Mission is to provide every village in the country with a trained female community health activist ASHA or Accredited Social Health Activist. Selected from the village itself and accountable to it, the ASHAs get training to work as an interface between the community and the public health system. Presently, 9,00,000 women stand enrolled as ASHA workers.

Requirements for Becoming an ASHA 

According to the Ministry of Health and Family Welfare, following are the requirements of becoming an ASHA:

  1. ASHA is mostly a woman resident of the village married/ widowed/ divorced; preferably in the age group of 25 to 45 years.
  2. A literate woman with due preference in selection to those educated up to 10th standard; wherever they are interested and available in good numbers. This ceases to be a requirement only if no suitable person with this qualification is available.
  3. Chosen through a rigorous process of selection, it involves various community groups; self-help groups, Anganwadi Institutions, the Block Nodal officer, District Nodal officer, the village Health Committee and the Gram Sabha.
  4. Capacity building of ASHA is viewed as a continuous process. An ASHA will have to undergo series of training episodes to acquire the necessary knowledge, skills and confidence for performing her spelled out roles.
  5. The ASHAs will receive performance-based incentives for promoting universal immunization, referral and escort services for Reproductive & Child Health (RCH); and other healthcare programmes, and construction of household toilets.
  6. Empowered with knowledge and a drug-kit to deliver first-contact healthcare; the NRHM expects every ASHA as a fountainhead of community participation in public health programmes in her village.
  7. ASHA is 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.

Other Guidelines for Becoming ASHA

  1. ASHA is a health activist in the community who creates awareness on health and its social determinants and mobilise the community towards local health planning and increased utilisation and accountability of the existing health services.
  2. She is a promoter of good health practices and also provides a minimum package of curative care as appropriate and feasible for that level and make timely referrals.
  3. ASHA will provide information to the community on determinants of health such as nutrition, basic sanitation & hygienic practices, healthy living and working conditions, information on existing health services and the need for timely utilisation of health & family welfare services.
  4. She will counsel women on birth preparedness, importance of safe delivery, breast-feeding and complementary feeding, immunization, contraception; and prevention of common infections including Reproductive Tract Infection/Sexually Transmitted Infections (RTIs/STIs) and care of the young child.
  5. ASHA will mobilise the community and facilitate them in accessing health and health related services; available at the Anganwadi/sub-centre/primary health centres; such as immunisation, Ante Natal Check-up (ANC), Post Natal Check-up supplementary nutrition, sanitation; and other services the government provides.
  6. She will act as a depot older for essential provisions made available to all habitations; like Oral Rehydration Therapy (ORS), Iron Folic Acid Tablet(IFA), chloroquine, Disposable Delivery Kits (DDK), Oral Pills & Condoms, etc.
  7. At the village level it stands recognized that ASHA cannot function without adequate institutional support. Women’s committees (like self-help groups or women’s health committees), village Health & Sanitation Committee of the Gram Panchayat, peripheral health workers especially ANMs and Anganwadi workers, and the trainers of ASHA and in-service periodic training would be a major source of support to ASHA.

Polio in India

India constituted over 60% of all global polio cases as recently as 2009. However, fortunately, in 2014, India officially became polio-free, along with the rest of the South-East Asia Region. Thanks to the singular commitment of the Indian Government at all levels, partners of the Global Polio Eradication Initiative, notably WHO, Rotary International and UNICEF; and more importantly, the ASHA Workers. India has not had a case single case of wild polio virus since 2011.

Important Role of ASHA Workers in Eradicating Polio

India’s last polio case occurred on 13 January 2011, and the country was certified polio free in 2014, after many years of concerted efforts led by the government of India with huge support from partners, including the World Health Organization (WHO), UNICEF, and Rotary. In an effort to eradicate polio, the world’s largest coordinated vaccination campaigns were launched; with millions of frontline workers vaccinating 170 million children aged more than 5 years in each national polio round.

Role of Various Frontline Health Workers

The role of Auxiliary Nurse Midwives (ANM); Accredited Social Health Activists (ASHA); Anganwadi Workers (AWW).

Health personnelASHAANMAWW
AboutConsists of community health workers instituted by the government of India’s Ministry of Health and Family Welfare as part of the National Rural Health Mission.They consist of village-level female health workers in India who serve as the first contact between the community and the health services. Regarded as grass-roots workers in the health organization pyramid.Anganwadi means “courtyard shelter” in Indian languages. Started by the Indian government in 1975 as part of the Integrated Child Development Services program to combat child hunger and malnutrition.
Type of compensationLocal volunteers receive outcome-based remuneration and financial compensationPermanent or contractual salaried health manpowerSalaried manpower under Department of Women and Child Development
Level of educationMinimum eighth standard passAuxiliary nurse midwife nursing course10 + 2
Training status7 training modules under National Health Mission. ANM acts as a resource for the training of ASHAs.Nursing course and various health programs trainingsJob training course and refresher trainings through Anganwadi training center
Major job profileThey work as first port of call for health and act as a link between community and health department. Provide health information to community, counsel and mobilize community for health services. Act as a depot holder for key drugs and logistics.They work at health subcentres. Expected to be multipurpose health workers. Work includes maternal and child health along with family planning services, health and nutrition education, efforts for maintaining environmental sanitation, immunization, control of communicable diseases, treatment of minor injuries, and first aid in emergencies and disasters.Their work includes conducting regular quick surveys of all families, organizing preschool activities, providing health and nutrition education to families, especially pregnant women on how to breastfeed, motivating families to adopt family planning, educating parents about child growth and development, providing supplementary nutrition to children aged <6 years and pregnant women, educating teenage girls and parents by organizing social awareness programs, etc.
Population servedOne worker for 1000 populationA single worker for 5000 population in plains and 3000 population in hilly and tribal areasOne worker for 1000 population
The role of ANM, AHSA, Anganwadi Workers.

Impact of Increased Number of ASHAs on Rural Immunization Coverage

As per a study by International Journal of Infectious Diseases, ASHAs have had a highly positive effect on vaccinations and immunizations for all other diseases for which routine vaccinations. They are essential in connecting families in rural areas with health care information and services. A critical aspect of their position is the promotion of vaccines. Significant associations between increased presence of ASHA workers and increased DPT and measles vaccination coverage at the district level in India corroborate the importance of their work and may call for expansion in their numbers and their role.

The average coverage of the Bacillus Calmette-Guérin vaccine (BCG), Diphtheria, Pertussis, and Tetanus vaccine (DPT), polio vaccine, measles vaccine, and full vaccine coverage (BCG, 3 doses of DPT, 3 doses of polio, and measles vaccine) across districts in India, was calculated and the impact of expanded ASHA presence on changes in district-level vaccine coverage evaluated.

They used District Level Household and Facility Survey data, collected in 2007-2008 (DLHS-3) and 2012-2013 (DLHS-4), districts are the unit of analysis. The changes in use of ASHAs and in vaccine coverage over time were calculated as the difference between district-level values in DLHS-3 and DLHS-4. For the logistic regression, analysing the relationship between expanded ASHA coverage and increased vaccination coverage, they dichotomized the change in ASHA presence at the median, and split vaccine coverage into two groups: increased and decreased vaccine coverage.

Results of the Study

Across the 267 districts in 21 states studied, 40.83% of villages within districts had ASHA workers in DLHS-3 on average, compared to 77.83% in DLHS-4. From DLHS-3 to DLHS-4, the average district-level coverage changed from 93.04% to 88.73% for BCG, 77.81% to 78.46% for DPT, 78.35% to 80.21% for polio vaccine, 80.93% to 79.08% for measles vaccine, and 62.88% to 50.95% for full vaccination. Greater than median increases in ASHA presence (≥30%) within a district were associated with 1.733 greater odds of increase in DPT coverage (95% CI: 1.036, 2.900) and 2.042 greater odds of increase in measles vaccine coverage (95% CI: 1.215, 3.430).

Expanded ASHA coverage was not significantly associated with changes in BCG, polio vaccine, or full vaccination coverage. ASHAs are essential to connecting families in rural areas with health care information and services. A critical aspect of their position is the promotion of vaccines. Significant associations between increased presence of ASHA workers and increased DPT and measles vaccination coverage at the district level in India corroborate the importance of their work and may call for expansion in their numbers and their role.

ASHA Workers Fighting COVID-19 as Frontrunners, Still Classified as Low Risk

After the COVID-19 outbreak in India; the duties of the ASHA workers were extended but the government did not do anything to provide them more protection. As per the Ministry of Health and Family Welfare’s Model Micro Plan for Containing Local Transmission of Coronavirus Disease (COVID-19), ASHA workers were instructed to make house-to-house visits to control the pandemic. They have to report symptomatic cases, then carry out contact tracing, maintain documentation, monitor the situation and create awareness among the local people.

ASHA Workers have been classified as ‘low risk’ suggesting only triple layered masks and gloves for them.
ASHA Workers have been classified as ‘low risk’ suggesting only triple layered masks and gloves for them.

The Ministry of Health and Family Welfare instructed the state governments to provide proper protective equipment to healthcare workers. However, in the Guidelines on rational use of Personal Protective Equipment, the Ministry classified the ASHA Workers as ‘low risk’ suggesting only triple layered masks and gloves for them. But in reality, it has become extremely difficult for them to even secure this minimum protection.

Aftermath of Media Reports Exposing the Truth

After many media reports brought out the real working conditions of the ASHA workers, some states provided them protective masks. For doing COVID-19 relief work, the government is providing them an inadequate amount of additional ₹2000. Still in many places, ASHA workers depend on the pity of the gram panchayats and city corporations which themselves rely on the district administration. Therefore, some panchayats received masks while others remain in waiting. Still, these panchayats have received only masks while gloves remain absent from the equipment.

Pitiable Condition of ASHA Workers

COVID-19 has left the ASHA workers in a pitiable condition. For a little and insufficient amount of additional money, they are made to put themselves and their family at risk. They face blame and are treated miserably by their families as they go out to perform their duties. Their communities accuse them of snitching as the symptomatic people are then transferred to quarantine centres. Moreover, they face stigma from the community as they are seen as carriers of virus as they go from house to house when they are social and health workers.

Earlier, ASHA workers used to visit houses and talk to women when the men were not at home. They could discuss freely about the health problems in the household. But in COVID times, they are looked down upon by men who criticize them and even sometimes indulge in violent behavior as they could pass the virus to the families. Many of their husbands have lost their jobs so they have no choice but to keep working and feed their families.

Strike By ASHA workers

Many ASHA workers have gone on strike to voice their protest of the paltry conditions they’re subjected to. About 6,00,000 of the ASHA workers went on a two day strike starting from August 7, 2020. They mainly demanded better pay and protective equipment. In Delhi, a huge number of ASHA workers have been on a strike since July 21. In the protest, the ASHA workers demanded that their salary be increased to Rs.10,000 per month from Rs. 4,000. The protest was launched by the All India United Traders Union Centre.

The Delhi Police on August 10 filed a first information report (FIR) against more than 100 Asha workers as well as members of Union for holding a protest at Jantar Mantar in contravention of the Unlock 3 guidelines in effect to prevent the spread of Covid-19.

Deputy Commissioner of Police (New Delhi) Eish Singhal stated that the FIR was filed against Section 188 of the Indian Penal Code, Section 3 of the Epidemic Disease Act and Section 51B of the Disaster Management Act. Singhal further said that the protesters failed to produce the required permits; when the police reached the spot on Sunday afternoon.

“They left Jantar Mantar after around half an hour, assuring they would submit the [permission] letter on Monday. However, nobody turned up on Monday, after which the FIR was registered,”

Singhal said.

Moreover, the police commissioner said that the ASHA workers were not wearing masks during the protest and did not maintain physical distancing rules.

The Way Forward

ASHA workers helped to eradicate polio and reduced the number of women dying during child birth. But in the present times, they are pushed to a breaking point. Under the Indian Constitution, Right to Health is a fundamental rights which is in violation in this situation. Similarly, they have a right to fair wages, safe working conditions, reasonable working hours. But most importantly they deserve gratitude, humane treatment with adequate institutional support for doing their work.

About the Author

Ishan Harlalka
I am a 3rd year law aspirant pursuing BA LLB. I am deeply interested in learning and am always looking forward to gain knowledge about new subjects. In my leisure time, I try to read books of various genres and by different authors. As people from non-law background may find it difficult to understand legal provisions and jargons, I try to write in a way that my articles are easy to comprehend and after reading them, one can discuss them with others.

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