Community health workers in rural India: analysing the opportunities and challenges Accredited Social Health Activists (ASHAs) face in realising their multiple roles

Abstract

BackgroundGlobally, there is increasing interest in community health worker’s (CHW) performance; however, there are gaps in the evidence with respect to CHWs’ role in community participation and empowerment. Accredited Social Health Activists (ASHAs), whose roles include social activism, are the key cadre in India’s CHW programme which is designed to improve maternal and child health. In a diverse country like India, there is a need to understand how the ASHA programme operates in different underserved Indian contexts, such as rural Manipur.MethodsWe undertook qualitative research to explore stakeholders’ perceptions and experiences of the ASHA scheme in strengthening maternal health and uncover the opportunities and challenges ASHAs face in realising their multiple roles in rural Manipur, India. Data was collected through in-depth interviews (n = 18) and focus group discussions (n = 3 FGDs, 18 participants). Participants included ASHAs, key stakeholders and community members. They were purposively sampled based on remoteness of villages and primary health centres to capture diverse and relevant constituencies, as we believed experiences of ASHAs can be shaped by remoteness. Data were analysed using the thematic framework approach.ResultsFindings suggested that ASHAs are mostly understood as link workers. ASHA’s ability to address the immediate needs of rural and marginalised communities meant that they were valued as service providers. The programme is perceived to be beneficial as it improves awareness and behaviour change towards maternal care. However, there are a number of challenges; the selection of ASHAs is influenced by power structures and poor community sensitisation of the ASHA programme presents a major risk to success and sustainability. The primary health centres which ASHAs link to are ill-equipped. Thus, ASHAs experience adverse consequences in their ability to inspire trust and credibility in the community. Small and irregular monetary incentives demotivate ASHAs. Finally, ASHAs had limited knowledge about their role as an ‘activist’ and how to realise this.ConclusionsASHAs are valued for their contribution towards maternal health education and for their ability to provide basic biomedical care, but their role as social activists is much less visible as envisioned in the ASHA operational guideline. Access by ASHAs to fair monetary incentives commensurate with effort coupled with the poor functionality of the health system are critical elements limiting the role of ASHAs both within the health system and within communities in rural Manipur.

Progress in maternal and child health: how has South Asia fared?

“…These have included deployment of community health workers through non-governmental health workers in Bangladesh 21 to public sector workers such as lady health workers in Pakistan 22 or accredited social health activists (ASHA) in India. 23 There have also been large scale experiments with community engagement through women's groups 24 as well and financial incentive programmes, both conditional on recipients' health behaviour, such as India's Janani Suraksha Yojana programme supporting facility births, 25 and unconditional, such as the income support programme in Pakistan targeting women. 26 Table 2 lists the key health initiatives implemented in South Asia during the period of the millennium development goals.…”

A home‐based, primary‐care model for epilepsy care in India: Basis and design

“…Clusters were selected from areas with lower sociodemographic indices, for which grassroots community health workers (Accredited Social Health Activists [ASHAs]) were available and willing to assist . A prevalence of 10 cases of epilepsy/1000 population was inferred from prevalence surveys in India, to which a 50% inflation was factored in to account for locked households, and for refusal to participate in screening or to enroll in the trial . A decision was made to screen about 2000 people in each screening cluster.…”

Impacts of community lay-leader health worker training and practice (Uttarakhand, India)

“…Participation in the course had also had an overall positive impact on candidates' self-confidence as well as their relationships with family members and villagers, echoing the experience of ASHAs in Manipur and CHWs abroad. 2,3,7 The activities of CLHTC graduates had also engendered a strengthening of relationships with local service providers, mainly in health but also in local governance roles. This was achieved in part through their activity within community structures and institutions: participating in (or initiating) village meetings, collaborating with local health practitioners, and establishing links with local schools.…”

“…This is an achievement that the ASHA program has not realised at scale. 3,13 Having developed "new beliefs and expectations about health and healthcare," CLHTC graduates have also gained an awareness of the extent and impacts of fraudulent practice. 12 Respondents noted that practicing alongside "quacks," as they called them, had created conflict with those providers and that villagers received conflicting messages about health and healthcare.…”

“…1 Acting as a link to formal healthcare services, CHWs also support or organise community development activities and data collection. 2,3 Worldwide, the specifics of CHW programs and activities vary greatly, however, and the National Health Mission of India initiated an effective CHW program in 2008 to train villagers as Accredited Social Health Activists (ASHAs) to expand healthcare coverage. This program alone remains insufficient to meet the needs of the large Indian population in rural areas, and the work of ASHAs has for the most part been limited to maternal and child health.…”