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01 Bihar_ASHA Monthly Meeting with AF

The ASHA Program in times of Universal Health Coverage - Old tensions in a new context

Shalini Singh, Baldeep Dhaliwal, Arpana Kullu, T Sundararaman

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.

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.

This commentary is in two parts. In the first part we revisit how different stakeholders conceived the role of the ASHA and then how these roles evolved in the first two decades of the program. (We will refer to their perspectives as “program theories” or “theories of change”). In the second part we deal with the challenges the programme is currently facing in addressing these tensions and the implications for the way forward.   The challenges explored in this perspective are drawn from the field research of some of the authors, conducted over the last year across multiple independent projects, which involved engaging with ASHAs and their support network. Various qualitative methods, such as interviews with key informants, participant observations, and focus group discussions, were utilized to gather insights from ASHAs and their support/supervisory staff across different states in India. This feature piece also refers to past studies, informing policy and program implementation.

Part I: The evolution of the programme:

The first phase- Multiple Program theories and roles of ASHA:

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.

Despite the dominance of a “service provider” and “link worker” roles, the concept of the “activist” also persisted in the understanding of the ASHA. There are number of  reasons for this…

Despite the dominance of a “service provider” and “link worker” roles for an ASHA, the concept of the “activist” never went away and persisted in the understanding of the ASHA/CHW. . First, the program’s name itself, “Accredited Social Health Activist” (ASHA), reinforced this perspective. Secondly, the program drew inspiration from Chhattisgarh’s Mitanin program, which was the first successful, scaled up and sustained CHW program run under government leadership. The Mitanin program began with “kalajathas”(folk theatres in tribal settings) promoting health rights and selecting local women activists as Mitanins (meaning friends). These activists were trained and supported through civil society-state partnerships to evolve as health activists. Right before the NRHM launch, this model served as role model for ASHA program and its success provided confidence that such programs could be implemented and scaled across states. Support institutions, like Chhattisgarh’s State Health Resource Center and State Advisory Committee, and national counterparts, such as the National Health Systems Resource Center and National ASHA Mentoring group, furthered this activism. The institutions enabled activist dimension to be emphasized in ASHA training programs, with a separate cadre of trainers often selected with civil society involvement to effectively communicate this aspect. The fourth reason was the ASHA’s own agency!. The program mandated middle school educated women,  resident locally and owned by  the community as ASHAs, fostering a sense of solidarity with their communities. Despite lacking regular payments and facing disdain from formal providers, ASHAs often prioritized community interests and their roles as friends and counselors. Her activism took various forms, from going beyond her duties and staying all night with pregnant mothers, persuading providers, to intervening for communities, or exerting social pressure. It reflected another dimension of activism- a worker who can be sensitized and, despite adversity, stays motivated to serve her people her community.  While studies highlight remuneration and hopes for regular employment as strong motivators, solidarity was also significant and has been captured effectively in some studies.

By 2011-12, there was widespread recognition within the government and program leadership of the necessity to integrate the three ASHA roles, which influenced the training and support strategy. The Eleventh Five Year Plan recommended prioritizing service provider training for ASHAs in newborn life-saving skills6. Inputs from field reviews7–9, evaluations10–12, and implementation experiences further addressed ASHA training and support challenges. As a result, the  revised ASHA guidelines of 2013 reaffirmed ASHAs’ roles and streamlined training and support systems13. Guidelines for Village Health Sanitation and Nutrition Committees (VHSNC) were introduced concurrently to integrate ASHAs’ activist functions with her service provider and facilitator roles. These developments led to a consensus across states on the roles of ASHAs and to some extent alleviated tensions arising from prioritizing one of the three rival theories.

The discourse had entirely changed by now. It was no longer about the necessity or effectiveness of ASHAs  or their roles, or whether they were an  ad hoc arrangement dependent on the NHM and viewed as a time-bound scheme. Rather, she had become a vital part of public health services, and the discourse involved balancing the growing demand for her services with her fair employment terms, clearly brought out in a landmark parliamentary report on “Working conditions of ASHAs” 14.

Policy evolution of ASHA as part of UHC (2015 and after)

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.

Part II. The Programme Today, and its challenges: Old tensions in a new context!

Health systems are complex systems, forever requiring learning inputs so as to adapt to changing contexts and internal developments.   Here, we examine the four contemporary challenges of the ASHA programme and suggest ways to understand and address them. These are: 1) the implications for ASHAs work of the shift from selective to comprehensive primary health care 2) the increasing burden of administrative and surveillance functions 3) the weakening of links of solidarity with the community d) the challenge to provide her with fair terms of employment and envisage her as a regular part of the public health workforce.

1. The Transition to Comprehensive Primary Health Care:-

As primary healthcare systems in India begin the transition to provide primary level care beyond MCH and infectious diseases, ASHAs require to adapt their work routine to now include new age groups, such as individuals over 30 years old and the elderly for universal screening, prevention, and management of non-communicable diseases (NCDs), alongside their existing outreach to eligible couples, pregnant/postnatal mothers, newborns, and children under 5.  Her services are now a part of integrated family-oriented models of care with a focus on disease prevention, basic curative care,  and health promotion based on the needs of all the different age groups 22. ASHAs, far from resenting this expansion, call for a further training to facilitate developing their workplans and make more productive household visits that can help them make the transition from addressing o only mothers and young children to family-oriented service delivery. A group of Sahiyas, (the name for ASHAs in Jharkhand)  put it thus-

We find it challenging to provide services to different people in the same household…… in a single household we have multiple beneficiaries, with varying needs, across different age-groups, mothers, children,… we are also required to take care of elderly (we have been recently trained in that), ,,,,,,each have diverse need for counselling, for newborns we do HBNC, for children under two, we do HBYC, fill CBAC forms for those above 30….it’s quite challenging.. some training is required to help us plan…. how do we provide care for the entire household now[FGD-Sahiyas- Jharkhand]

Counselling, screening encouragement, risk assessments, follow-up care, and referral coordination are essential across all age-groups in CPHC. ASHAs require guidance to integrate these tasks into holistic home visits as compared to visits focused on single top-down priorities like immunization or newborn care.

One approach to re-thinking the work plan is based on the number of households covered by ASHAs. Household visit numbers and the time per visit should now be based on integrated and increased health issues addressed, not just single service visits. Current stipulation of 1000 individuals or 200-250 households is the upper limit and may require better ratios of ASHA to population ratios for her to  be  effective. Thailand has for example one CHW for 20 households. Chhattisgarh itself has the same proportion as Anganwadi’s, one for 80 to 100 households. A second ASHA for every 1000 population which effectively brings the ratio down to 1 per 500 individuals is also a viable option.

It’s essential to consider that deploying ASHAs effectively will bring many latent cases into formal care pathways. One study estimated that only one in three diabetics, one in 7 hypertensives, about 1 in 25 patients with arthritis and one in 100 patients with clinically significant depression are receiving the medical care they require, with the rest not accessing formal care 23.  Just as  the primary care system struggled to cope with the institutional deliveries once the ASHA started bringing them in, public health services would also struggle if the ASHA is able to reach out to all the communities’ health needs, latent and overt.

Therefore, to meet the increased demand resulting from expanding ASHAs’ facilitatory role for a broader range of diseases, a better functioning of HWCs is needed.  To achieve this, it is crucial to establish robust referral systems and improve  access to specialist consultations . If coupled with the right to healthcare act, such an expansion of  ASHAs’ roles could create a system where necessary health services are universally accessible and can be delivered as an assured entitlement Despite the declaration that upgradation-to-HWC targets have been met, the fact is that such expansion is still at an early stage and while some states have made significant progress, in many the changes are minimal and have even characterized as cosmetic 23A. The limiting factor in ASHA undertaking this expanded set of services is not because of lack of her capacity. Rather, it lies in the lack of capacity of the rest of the district health system to respond to the pressures her effective functioning would lead to.

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.

3. Weakening Links with the community:-

The Village Health, Sanitation and Nutrition Committees (VHSNCs) in rural areas and the Mahila Arogya Samiti (MAS) were proposed as local institutions for community engagement, to optimize health outcomes, monitor public service delivery, and address social determinants of health. Unfortunately, in the past five years, the efforts to keep this VHSNC functional have tapered off 28,29. Interactions with ASHAs across states revealed this is partly due to problems of weak community participation due to lack of clarity regarding its objectives and benefits and excessive messaging regarding RCH services. Other reasons for poor performance of these community institutions (as reported by previous assessments) include – limited alignment with existing elected institutions of local governance;  lack of equitable participation; and reluctance of  government administrative frameworks to expand the reach of such health committees 30.

One important consequence of the weakening of institutions of community participation is the weakening of the ASHA’s links with the community, especially where ASHAs were convenors or were otherwise playing a leading role in the VHSNC and MAS.  Committees, though irregularly convened, fostered solidarity between ASHA and the community, aiding in awareness and mobilization tasks. Collaborating with the community increased her sense of accountability, fostering a non-confrontational relationship, and aligning with community health worker roles .

It’s worth emphasizing that the relationship between healthcare providers and users, including ASHAs, is one of co-production, not just producer-consumer. Communities are active participants, not passive recipients. Solidarity is essential, and health systems must invest in fostering it, recognizing it as an ongoing process. There is a complexity in this relationship. ASHAs’ engagement with the community must include addressing social determinants and the community level issues like early childhood marriages, caste discrimination, substance use disorders, domestic violence, and more. This could bring them into conflict with dominant sections of a heterogenous community. Institutional structures that provide state and system support for ASHAs are essential in navigating these challenges. What is at stake is not only the imagination of the ASHA’s role but the imagination of primary healthcare itself. This relates not only to Governments. Even trade unions and civil society associations, alongside their legitimate and welcome focus to secure ASHA her economic and gender – based rights as a woman health worker, must find ways to bring in a new ethos. This would mean promoting an organization of health care (relationships of production) that is consistent with such an imagination of primary healthcare and health rights.

4. Issue of Financial Compensation- Motivation, Retention and Fair Play:-

The debates surrounding financial compensation and regularizing ASHAs are critical and have become central to the present discourse.  Ongoing demonstrations and protests by ASHA Unions underscore a prevalent sense of injustice, stemming from the current performance-based incentive structure, excessive workload owing to administrative tasks, and their classification as volunteers rather than workers. Implementation hurdles, such as intricate payment systems and the cumbersome process of verification and documentation for incentive claims, compound ASHAs’ p experience of unfair treatment.

At the international level, recent WHO guidelines have asked for fair compensation and support for career progression, with a call for  both financial and non-financial incentives for community health worker motivation and retention 31.  In India, there is  a steady flow of announcements of increased payments by central and state governments 32,33 in response to demands from ASHA Unions and in many states there is a significant increase- but no fair wage policy has emerged, despite support from both civil society and political parties. Clearly there are bigger barriers at work, which we must understand and navigate a way around.

The ASHA is now an integral part of public health services, but it’s crucial to recognize that she isn’t a low-quality or ad-hoc substitute for a clinical provider. Her tasks require someone selected from and residing in the community, familiar with its language, customs, and idioms, and who can be trained to guide the community to protect their health and choose the most appropriate, optimal care pathways when in need of healthcare. Employment terms must protect her unique role.

Making ASHAs regular employees via standardized merit criteria through public service selection process might jeopardize their close community connection. In the initial phases in Chhattisgarh’s tribal areas, even illiterate women were selected and succeeded as Mitanins. Conversely, in tribal areas of states where education requirements led to non-resident ASHAs unfamiliar with the community being selected, effective outreach had suffered 5.

One solution is to have ASHAs employed by local bodies, selected, and deployed with support from a state organization to balance local power dynamics. Funds and training support would come from the program. This model has been seen mainly in Kerala. But success would depend on the state of the panchayats. Trade unions, favoring employment terms on par with ANMs, oppose this approach. Another option is legislation allowing fair employment terms for ASHAs, diverging from typical public service norms.

Another reason attributed for maintaining ASHAs within a contractual status, is the fear that regularization (with or without unionization) would lead to reduced accountability.

There is little or no evidence to support the notion that contractual workers outperform regular employees, and yet this perception holds strong in administrative circles. The suboptimal performance of many regular health workers, particularly male multi-purpose workers, may stem more from inadequate work distribution, support, and supervision rather than unionization. Besides performance and unions, managing a regular workforce brings about extensive litigation, draining leadership resources due to the complex web of government employment rules that make legal challenges easy, while bringing about reforms is quite challenging. A significant administrative overhaul is necessary to integrate modern human resource management concepts into public administration. Contrary to popular belief, countries with universal healthcare often have robust trade unions and labor rights. Many government employment rules, crucial for equitable recruitment to administrative roles, may not be beneficial for those delivering public services directly. Learning from successful public administration models is vital to develop employment terms that balance fair wages, social security, and functionality for community-facing roles.

But perhaps the most deep-rooted barrier is the understanding of the role of government in current economic policy. Public employment of any sort is seen as a burden on the budget which is best minimized. Overcoming this requires two major commitments. The first is a commitment to public financing of a public health service which delivers universal healthcare as an entitlement and as one of the pillars of a welfare state. If ASHAs are an integral part of public health services, ensuring the ASHA’s fair terms of employment and making efficient use of her services (viz ensuring that the money spent on her salaries is ‘value-for-money’) both require such a commitment. The second is a commitment which envisages full employment with social security as one of the main aims of public policy. Deployment of such a large workforce, so evenly distributed across the entire population, is a big leap forward in this direction. As more and more jobs are lost in the manufacturing sector, and in agriculture, it is in the care sector that new jobs can be created- what has been characterized as a ‘caring’ economy. In most developed countries, as much as 10% of the entire workforce is employed in the healthcare sector. India is far from that. When government budgets are willing to consider universal basic income schemes, and cash transfers of many sorts, the reluctance to concede a minimum working wage for the ASHA is indeed very short-sighted.


The future of the ASHA programme and the future of UHC hinges on overcoming challenges that hinder ASHAs ability to fulfill her role as part of a comprehensive primary health care approach. This includes re-imagining the organization of her work agenda. By limiting the population that each ASHA caters to, and by her being part of an adequately trained and supported primary care team, this work load can be managed. The caveat is that each additional health issue she addresses should not carry along an additional layer of administrative work, leaving her with reduced time for care provision, and altering the imagination of her role. Success in this new role would depend more on how the HWC and district health system rise to the provision of comprehensive primary health care, than on her capacity in isolation. The other challenge is revitalizing community engagement structures to empower her as an activist to reach the vulnerable communities and address social determinants of health. Her future trajectory also relies on government’s strong commitment to public health services and welfare as public goods. The organization of CPHC must ensure that both fair employment conditions and upholding the community solidarity that she has fostered over multiple years are secured.

ASHAs are chosen by/for their communities as health advocates, and as cultural mediators, thereby holding a unique trust. Their deep understanding of community dynamics is required to bridge the gap between healthcare services and the community. Preserving their role as community representatives, rather than functioning solely as government employees, would be crucial to preserve the community’s rights to health.  There is a need to think through the systemic requirements that would provide adequate monetary compensation with social security while ensuring that she can be responsive to community concerns and the needs of marginalized sections.  Just as fair compensation is vital, maintaining trust between ASHAs and communities is equally crucial. While these problems may be amenable to resolution within the current system, addressing the economic policies of the day to enable such a transition is a much more difficult challenge.

  • Dr Shalini Singh, currently Public Health Researcher based in Bengaluru, former Senior Consultant, Community Processes Division, NHSRC, New Delhi.
  • Ms Baldeep Dhaliwal, Doctoral Student, Bloomberg School of Public Health.
  • Ms Arpana Kullu, Doctoral student, Tata Institute of Social Sciences, Mumbai.
  • T. Sundararaman, Convenor, Right to Health Resource Collective, Former Executive Director, NHSRC, New Delhi.

Acknowledgements: Dr Mekhala Krishnamurthy for peer review and comments. Dr. Bitty Raghavan, Senior resident, Department of PSM JIPMER Karaikal, for her inputs with regard to reference articles on ASHA workers.

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    North India, Economic and Political Weekly, Vol. 59, Issue No. 8, 24 Feb, 2024
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  26. Khandre RR, Jakasania A, Raut A. “We are working for seven days a week” :Time motion study of accredited social health activists from central India. Medical Journal Armed Forces India. 2023;79:S142-S149. doi:10.1016/j.mjafi.2022.03.008
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  28. Fathima FN, Raju M, Varadharajan KS, Krishnamurthy A, Ananthkumar SR, Mony PK. Assessment of ’accredited social health activists’-a national community health volunteer scheme in Karnataka State, India. J Health Popul Nutr. 2015;33(1):137-145.
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  33. PM announces increase in remuneration for ASHA and Anganwadi workers. Accessed April 15, 2024.

Pradhan Mantri Jeevan Jyoti Bima Yojana (PMJJBY)[1] Central government backed life insurance coverage of Rs 2 lakh for every ASHA at just Rs 330 annual premium borne by the state governments.

Pradhan Mantri Suraksha Bima Yojana (PMSBY)[2] Accident insurance coverage of Rs 2 lakh for every ASHA at just Rs 12 annual premium borne by the state governments.

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