Collapsing at the last mile

Public health system

Nearly 30,000 Accredited Social Health Activist (ASHA) from across Karnataka held a massive rally and a day-long protest in Bengaluru on Friday. ASHA are honorary volunteers and receive performance-based compensation based on reported activities. They are demanding a fixed monthly payment of Rs 12,000 and delinking of the Reproductive Child Health (RCH) portal from ASHAsoft, the Centre’s online payment system for ASHA. They are also demanding immediate payment of their incentives that are due for the last 15 months. There are about 42,000 ASHA working in some 29,000 villages of Karnataka. The Karnataka State United Asha Workers' Federation (KSUAWF) has decided to stay off duty until their demands are met.

The ASHA programme was introduced in 2005 as a key component of the National Rural Health Mission to strengthen rural public service delivery and bring about community engagement in health programmes. In 2015, the programme matured into the National Health Mission and was extended to marginalised urban areas. One ASHA is selected per 1,000 population. They are women aged between 21 and 45 years and have basic school education, between Class 8 and Class 10. After induction, they are trained for about 23 days spread over 12 months. In Karnataka, ASHA are paid a fixed sum of Rs 6,000 per month, of which the state contributes Rs 4,000 and Rs 2,000 comes from the National Health Mission. In comparison, the Andhra Pradesh government now pays Rs 10,000 as monthly honorarium to ASHA.

The ASHA are also entitled to incentives between Rs 3,500 and Rs 5,000 per month. Their incentives are based on specific services delivered, such as antenatal care that involves four visits to the pregnant woman, two TT injections (Rs 300), institutional delivery at a government facility (Rs 300), completion of all immunisation for a child (Rs 100), following up on low-birth weight babies (Rs 50 per month), ensuring spacing of birth between children (Rs 500 per case), and attending Village Health, Sanitation and Nutrition Committee Meeting (Rs 150), etc.

According to government guidelines, her working arrangement is supposed to be flexible and limited to about two-three hours per day, four days per week, except during some mobilization events and training programmes. In reality, her working hours stretch far beyond even full-time work. ASHA are responsible for nearly 36 different kinds of tasks, such as creating awareness and providing information to the community on various health programmes, nutrition, sanitation and hygiene. They register all pregnant women, provide three antenatal visits and two postnatal visits, counsel mothers on birth preparedness, safe delivery, breast-feeding, feeding practices, immunization, prevention of common infections, tuberculosis, malaria and family planning. To this central list, the state health department, the Deputy Commissioners and their own centres pile on more tasks. As if that’s not enough, they are also regularly assigned to conduct many surveys, and are called to attend meetings and jathas at their own cost.

The compensation is not just disproportionately low for the work they do, but also very irregular. Their incentives are not paid monthly, but in a piecemeal fashion. State incentives are separately paid, the Centre’s MCTS and non-MCTS payments are done separately, too. They receive these payments sometimes after six months or even a year. They do not even comprehend what they are paid for and for which service/month. They are unable to track payments. On many occasions, despite being eligible for incentives of Rs 3,000 or more, they end up getting as little as Rs 800. Payment systems have been changed frequently, making it difficult for them to keep track.

ASHA are supposed to register their services in RCH/ASHAsoft. ASHAsoft is an online system for the health and family welfare department to capture beneficiary-wise details of services provided by ASHA to the community. It is an online payment platform of ASHA, direct to their bank accounts.

But they are at the mercy of intermediaries such as data entry operators and Auxillary Nurses and Midwives at the primary health centres to enter their service data into ASHAsoft. When there is a delay in entry because of the intermediaries or an internet issue, their payment is further delayed.

Currently, the government (Union and the states put together) spends roughly 1.13% of the GDP on health, which is grossly inadequate for a country of India’s size and very low compared to health spending by other countries. As a result, 62% of healthcare spending is financed by households through out-of-pocket expenditure at the point of care.

The ASHA are a bridge between the rural population and the government health system. They have played an important role in reducing maternal mortality and infant mortality. Apart from increasing their pay, it is also imperative that their workload is rationalised, especially their repeated survey-related tasks. Improving their work conditions is extremely important. For example, they work as DOT-S (Directly Observed Treatment Short-course) providers for tuberculosis treatment and bring samples to the nearby health centres. However, they are not even provided basic safety gloves for the task. They accompany pregnant women (during delivery) and children for treatment even during odd hours and to distant health facilities. However, they do not get facilities to rest in those centres. Sometimes even staff in those centres do not treat them properly.

With almost a million ASHA now trained and working throughout the country, it has become one of the largest Community Health Worker programmes in the world. Unless the government responds to their demands with care, the backbone of the social health network at the grassroots level will be crippled. Many ASHA are motivated and take pride in the work they do. To sustain this, it is important to continue to invest in them and to ensure that the existing ASHA have the institutional support to deliver the ever-expanding set of services expected of them.

The ASHA programme has over the last decade been successfully connecting marginalized communities to public health services. Given their potential to impact service utilization, there is a need to streamline payments due to them and better incentivize them for their work. Their demands are justified. The State should stop exploiting them.

(The writer is a Research Consultant at Ramalingaswami Centre on Equity and Social Determinants of Health, Bengaluru)