ASHA is India’s community health worker. With nearly 900,000 women volunteers across the country, the programme has survived for a decade. Unlike earlier community health worker programmes, it shows little evidence of withering away in the near future. I would like to raise two issues in this piece: One, what made the ASHA sustain over this decade in India? And the second, what are the key issues that need to be addressed to sustain the programme over the next decade? Being one of the largest national community health worker programme, there are several lessons for global health from India’s ASHA experience.
Firstly, the ASHA was not launched as a stand-alone effort at improving health care. She was part of a health system reform initiative, the National Rural Health Mission (NRHM) launched in 2005. The NRHM viewed community engagement as an organic link to health systems strengthening activities such as improving infrastructure, expanding the numbers of nurses and doctors, developing mechanisms to improve access and coverage such as ambulances and mobile health services, and building systems to address supplies and logistics. There was also a clear articulation for her selection (by the community) and of her three roles as a facilitator, a social mobilizer or activist, and a provider of community level care. ASHA’s financing, is through a form of remuneration in which she is paid fixed amounts linked to specific tasks. A dedicated human resource cadre for supportive supervision of the ASHA was also built in. There was also a systematic process devised for developing standard guidelines and mechanisms, in the local language for training and support of ASHAs. There is some evidence to show that the role of the ASHA in encouraging communities particularly mothers and children to health facilities for institutional deliveries and immunization is significant.
While on one hand, there may not be a high degree of political commitment to the ASHA programme, on the other hand there is also a reluctance to disengage from the programme, especially given the large numbers of ASHAs and the political constituency that the she represents. As health systems in India mature, it is still to be seen how the roles of facilitator and activist balance with those of a service provider for maternal, new born and child health. Over time, India will also have to answer difficult questions on community health workers. Should there be criteria for turnover and renewal? How should her roles evolve to suit emerging diseases? Should more qualified ones replace less qualified health workers or will community choice prevail? What will be the career pathways for such health workers? What then are the implications for community embeddedness? These are indeed difficult questions for any community health worker programme, but there is no doubt that a robust community-embedded health worker programme such as the ASHA is crucial to health systems in India and possibly in several other countries.