Comprising a million, informal, female health workers, India’s ASHA program, stands as the most prominent Community Health Worker (CHW) initiative both nationally and globally. Approaching nearly two decades since inception, ASHAs have become the cornerstone of India’s primary healthcare system and thereby a major contributor to the delivery of healthcare rights. At the 75th World Health Assembly (WHA) on May 22, 2022, ASHAs were honored with the Global Health Leaders Award, acknowledging their pivotal role in connecting marginalized communities with health services and recognizing their efforts in ensuring access to primary healthcare, amidst the challenges posed by the COVID-19 pandemic ¹. As we commemorate World Health Day 2024, we felt it is an opportune time to pause and reflect on the uncertainties and problematics confronting the programme, both at the level of policy and at the level of the workers themselves.

The value of  CHWs in expanding coverage and universal access to essential health services is clear and can no longer  be overlooked ^2,3.  Robust CHW programs play a vital role in expanding health services to reach  the underserved population across many countries ⁴. Recent health crises like Ebola and COVID-19 underscore the vital role of CHWs in early detection, monitoring, and containment-highlighting that well-trained CHWs are essential for both health security and universal health care ². The large diversity in CHW programmes reflect the different health systems contexts in which they emerged, the different ways in which their roles were conceptualized and how the tension between accountability to the health department, to the community, and their own requirements for fair working conditions and terms of employment were reconciled. These relationships are never static. Today, as countries commit to progress towards Universal Health Care (UHC) or Health for All, they all face the common problem of how to make the best use of the enormous potential of this work force in achieving UHC while ensuring fair working conditions and terms of employment and retaining the special “community worker” character of this unique work-force.

ASHA program was a major component of the National Rural Health Mission launched in 2005. The program was initially limited to 18 states with poor maternal and child health indicators, along with tribal areas of other states. Its initial focus was on promoting demand and universal access for RCH services and select disease control programs.

Considerable resistance emerged against such limited understanding of the ASHA’s role, with a section of  civil society advocating for her as an activist and others endorsing her as a link worker, while still others perceived  her as a service provider for essential services. Agreement on these roles was not easy, both within civil society and in government.  National consultations, a task force formation, and integration of their recommendations into the ASHA Guidelines ensued thereafter and conceptualized her role as consisting of a mix of all three functions. Yet, state and national stakeholders had differing interpretations of the guidelines, resulting in varied trajectories for ASHAs across states and diverse perspectives about their roles⁵.

A study by the National Health Systems Resource Centre in 2009 (published in 2011) examined the ASHA Program’s first five years, exploring the impact of varied interpretations of her role. This study categorized different approaches into three “program theories”⁵ for analysis. A cross-state comparison was then conducted to discuss the advantages and limitations of each approach.

The most common “Link Worker” approach, categorized as Program Theory 1, saw an ASHA primarily as a facilitator for accessing government health services, focusing on promoting institutional delivery, contraceptive use, and immunization. This approach minimized her role as a service provider or activist, with payments tied to a few priority tasks. While it led to better program ownership by the health department and immediately improved access to immunization and institutional delivery, it reduced an ASHA’s ability to respond to community needs, failed to address concerns related to newborn and child mortality, and limited her credibility and motivation to reach marginalized populations.

Program Theory 2 drew from NGO programs, and prioritized ASHAs as “service providers” offering essential health services and health education. ASHAs received training in basic curative care and were equipped with a drug kit. While their role as care providers complemented their link worker role, payment primarily came from the latter. This approach improved ASHA’s credibility and effectiveness in addressing immediate health needs, particularly in marginalized communities. By 2009, the program expanded to all states except Tamil Nadu, where they did not ask for it and therefore the program remained limited to tribal areas.   Subsequent well-structured  training in 2010 to equip her to provide home based newborn care further systematized their role in newborn care and addressing sick child healthcare needs. Gradually, ASHAs also took on facilitatory and care provider roles in various disease control programs-TB, HIV, malaria. The success in these roles led to an overwhelming increase in ASHAs’ responsibilities, triggering demands for regular pay and government employee status. Even as studies and committees bemoaned the increase of tasks, even more tasks were added on. There was growing support for ASHA’s demands for regular pay from civil and political society. These are the concerns critics of this approach had warned against and a reason for many states resisting the program in the initial years. During the structural adjustment years (1993 to 2005) all recruitment, even of vacancies in existing doctors’ and nurses’ positions had ceased in most states. Not only did NRHM reverse this policy, but it facilitated employment for a million women health workers, (even though on an informal project-linked basis) – by no means a small achievement.

 Some global institutions had favored an alternative approach: developing ASHAs as agents paid on commission to “market” a wider range of services. Such an agent could have generated demand impartial to private or public providers, with referrals driven more by incentives. But, by  the second decade, ASHA had developed the consciousness of public services as a social good. Hence, this market-based perspective is less visible now than before. However, like all past theories, such theories do not fade away completely. They only get shelved and can re-emerge

Program Theory 3 views ASHA as an “activist,” focusing on her role in reaching marginalized communities and empowering them to assert their health rights. Advocates of this perspective worried that both the link worker and service provision approaches could divert ASHA from a rights-based approach and potentially duplicate or shift responsibility away from state workers. This viewpoint draws partly from influential literature such as David Werner’s book “Community Health Workers: Liberators or Lackeys,” which greatly influenced civil society and public health discourse by highlighting ASHAs’ potential as health rights activists. However, it remained uncertain how this activist role could be sustained within a nationwide government-run health program.

With the growing clarity on the ASHAs roles and their recognition as an inherent part of the India’s healthcare system, health policy henceforth could clearly stipulate their involvement as central to the primary healthcare team within the UHC framework. The High-Level Expert Group for Universal Health Coverage proposed doubling the number of ASHAs, from one per 1000 to two per 1000 in rural areas, so that an expanded set of roles which included NCDs, and mental health could be addressed ¹⁵ . The National Urban Health Mission launched in 2013 recommended ASHAs for low-income urban areas, assigning them roles in preventive care, health promotion, and advocating for health entitlements ¹⁶.

By 2014, the requirement for a fixed monetary compensation was conceded. A blended payment model with fixed compensation for regular activities and performance-based incentives which had incentives linked to individual service delivery counts was adopted. The quantum of incentive for ASHAs routine-recurrent activities (mobilization for monthly health promotion days, surveys, maintaining records, line listing of beneficiaries) was introduced at Rs 1000/month in 2013 and later increased to Rs 2000/month in 2018 ¹⁷.

Guided by the 2015 Task Force Report on Comprehensive Primary Health Care (CPHC) Rollout, later endorsed by the 2017 National Health Policy, the Ministry of Health, and Family Welfare (MoHFW) initiated efforts to enhance existing primary healthcare facilities. This transformation aimed to shift primary level care from providing a limited package of services, addressing less than 15% of primary healthcare needs, to a comprehensive approach covering 12 service areas that addressed most healthcare needs. The expanded range of services were to be delivered through a set up which was later termed the “Ayushman Bharat -Health and Wellness Centers (HWCs) These essentially provided for an upgraded 146,000 health sub-centres and about 26,000 primary health centres. The ASHA was perceived in this report as integral to the primary care team of the HWC. The CPHC vision didn’t suggest increasing ASHA numbers beyond 1:1000 but broadened their roles from focusing on Reproductive and Child Health (RCH) and national disease control programmes to include mental health and NCDs and palliative and geriatric care across all states. It recommended leveraging ASHA and VHSNC network to optimize health production, focusing on early risk assessment, medication continuity, patient follow-up, and community support ¹⁸.  New training and support guidelines for ASHAs emerged on this basis. ¹⁹. This broader work definition transformed ASHA from an ad hoc arrangement for some immediate specific targets,  to an integral institution within public health services, to be sustained and supported indefinitely.

New incentives were made available for risk assessment, screening, and follow-up for NCDs and to support an expanded package of services. 27 out of 29 states with ASHAs are also providing top up or fixed incentives ( ranging between 500-10,000 per month) to ASHAs from the state budgets ²⁰. To augment support for ASHAs ,other welfare measures were also expanded.  Recent reports state that around 62% ASHAs are now participating in Pradhan Mantri Jeevan Jyoti Bima Yojana (PMJJBY)[1], and 68% in Pradhan Mantri Suraksha Bima Yojana (PMSBY)[2] ²⁰. States like Chhattisgarh have more elaborate social security arrangements in place- though these are well short of what, for example, the ESI scheme provides.

Another significant component of India’s UHC plan, outlined in the National Health Policy,2017, is the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) ²¹. This publicly funded health insurance scheme merges with various state-level programs. There were efforts to involve ASHAs in PM-JAY, but except for initial publicity and assistance in enrolment this did not go far. Instead  , another cadre of volunteer workers known as Arogya Mitras have been introduced in the health facilities to support enrollment, referrals, and insurance claims of the beneficiaries. The concern is that in this contested interface between different parties, and within the ethos of market competition, the alignment of the Arogya Mitra could be more with the insurance agency and/or the provider than the beneficiary. This requires further study. Top of Form

In Summary: The change that has taken place within a relatively short period of about 15 years is truly amazing.  There are now around 9.83 lakh women working as ASHAs against the target of 10.35 lakhs (NHSRC website, 2021) and estimates put ASHA requirement for UHC at 1.9 million ASHAs  ¹⁵. The achievements in training them are also impressive with 90% of rural ASHAs and 71% of urban ASHAs completing training in MCH and infectious disease management competencies. Additionally, 66% of rural ASHAs and 75% of urban ASHAs have received training in NCDs. Furthermore, training in the expanded services for CPHC is gaining traction, with 30% of ASHAs already trained ²⁰. The need for an independent support structure, once a highly contentious issue, is now accepted as a requirement and over 90% of positions of supervisors at district, block, and cluster levels are now filled.

With the adoption of a comprehensive primary healthcare approach built around the Health and Wellness Centres (HWCs), and with ASHAs acknowledged as integral to this approach, a significantly new situation has emerged. What are the new forms that the old tensions have taken in this new context and how could these challenges be addressed? We address these issues in the next section.

2. Over-emphasis on data collection, -multiple surveys and burden of reporting:-

Studies have shown that maintaining registers and managing reporting forms place a substantial time burden on frontline workers. ²⁴ This is particularly true for ASHAs, as work is typically delegated down the chain of responsibility. ASHAs are expected to complete reporting responsibilities for a range of tasks, including overall household records, maternal and child health records, and online registration among others.

 “Quite often ASHAs are tasked to update line lists and service utilization details in the RCH portal by their sub-center ANMs. They travel to block headquarters, or district hospital in urban settings for this…. incur transport expenses and are never compensated”. [Program administrator-Madhya Pradesh]

ASHAs were  expected to work 10-15 hours per week. Currently their work is closer to 30 hours per week. However, studies in central and south India found that, on average, they spend more than 8-10 hours per week only on reporting, filling registers, and conducting surveys ^{25 26}. The adverse impact that the burden of reporting has on service delivery is often perceived and expressed by the ASHAs in terms of taking time away from incentive-linked tasks:

“We get money from going around – not from this kind of work.” [ ASHA-Punjab]

The challenge of multiple surveys in a year to enlist the beneficiaries has been reported earlier ²⁷ and emerged several times in our discussion with ASHAs across multiple states. ASHAs in Karnataka mentioned conducting 15 surveys for diverse national health programs in one year.

ASHAs often engage in non-healthcare tasks, like surveys, adding to their workload. They are expected to manage this extra reporting alongside their regular maternal and child health duties. As one health officer ruefully stated:

“At least with the Ayushman cards, these are still related to health. They’ll even tell us to bring ASHAs into the elections if they need to.” – [District Health Officer Punjab]

Another example of administrative work distracting from her care-giving work is ASHAs being tasked to prepare the Ayushman Cards for beneficiaries to avail the health insurance benefits under PM-JAY. Many times, the beneficiaries phone numbers do not match  with the Aadhar card and there is pressure on ASHAs to authenticate these credentials. As one  program administrator asked-

“Why can’t the responsibility of updating and authenticating the credentials be taken up by community service centres and panchayats……it would save time for ASHAs to focus on their service delivery functions.” [Program Administrator-Jharkhand]

But perhaps the more important challenge of excessive reporting and administrative tasks is that they often replace actual care provision and distort the imagination of what her role is. For instance, ASHAs’ role in preventing and promoting NCDs may be limited to completing Community Based Assessment Checklists (CBAC) forms. These forms aim to identify and mobilize high-risk NCD cases in individuals over 30 for screening. A program officer in Chhattisgarh highlighted multiple challenges with respect to this task –

“So, the next issue is…. that even if Mitanins have filled out the CBAC form and submitted it, it is counted as work for payment of a linked incentive only when it is entered into a portal.  The first issue is a shortage of CBAC forms, the second is that the CBAC form that has been filled is not being entered, and the third is that even if the entry is happening, there is no final use of it for service provision in the form of counselling or referrals. These are the three main issues related to the CBAC forms” [Program Administrator-Chhattisgarh]

Her solidarity as a care provider is further impacted as the act of data collection and entry becomes delinked from and eventually substitutes for care provision. Her primary accountability to the community and marginalized individuals shifts to administrative tasks disconnected from health outcomes. These problems are neither novel nor inevitable. Rationalizing data collection and prioritizing community interaction can alleviate these issues, ensuring thereby that most of a provider’s time is spent on direct service delivery.