The backbone of India's health care system: Is there a new role for ASHAs?

A community health worker at a health facility in India. Photo by: The White Ribbon Alliance / CC BY-NC-ND

KATHMANDU, Nepal — India has experienced a dramatic transition from a huge burden of infectious diseases to noncommunicable diseases, which now cause more than 60 percent of deaths in the country — almost 6 million each year. As urbanization, combined with unhealthy diets, a lack of physical activity, and tobacco and alcohol use show no sign of abating, there are concerns that India will miss its national goal of reducing the number of premature deaths from NCDs by 25 percent by 2025. Without action on NCDs, the World Economic Forum predicts India stands to lose $4.58 trillion before 2030.

Community health workers, known as accredited social health activists, or ASHAs, form the backbone of India’s health care system. Based in their own communities, ASHAs are local women between the ages of 25-45, who act as an interface between their community and the public health care system. This 800,000-strong workforce doesn’t receive a salary, but instead gets small cash incentives for their work.

How are ASHAs paid?

In 2005, the Indian Ministry of Health and Family Welfare instituted ASHAs as a key feature of the National Rural Health Mission, which has the goal to provide accessible, affordable, and quality health care to the rural population. The Indian government pays 60 percent of ASHA compensation, with the remaining 40 percent paid by the states. The states define the amount of the incentives paid to their ASHAs, but the government makes sure there is some parity. However, some states have started introducing small fixed salaries in addition to the incentives.

Historically, their primary tasks have been focused on maternal and child health services such as counseling women on contraception, pregnancy, safe delivery, and facilitating vaccinations. But given the lack of access to health care in rural and remote areas, some believe ASHA workers — who are respected and trusted members of their communities — could hold the key to helping India combat its growing NCD burden.

A new role for ASHAs?

A recent study led by researchers from the George Institute for Global Health found that ASHA workers could be used to identify and control high blood pressure in the community. It also found they could be trained to lead community-based group educational discussions, and support community members in the management of high blood pressure.

During a five-day training, a group of ASHAs in southern India learned strategies in how to manage hypertension, measure blood pressure and weight, in addition to facilitating patient-community meetings.

“If you give some level of training, ASHAs can be effective at screening for hypertension and diabetes,” Pallab Maulik, deputy director of the George Institute for Global Health in New Delhi and one of the authors of the study, told Devex.

“I think they feel very empowered — and that’s a word coming from them, not from me,” he said. “They really feel that getting these tools has helped them.”

The study is part of a broader pilot by India’s National Programme For Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke to train ASHAs to prevent and manage chronic diseases and their risk factors. Maulik said given the resources and time it would require to train additional health care professionals, ASHAs were well suited to providing such care in a cost-effective manner.

“When an ASHA is at a home for a visit, it only takes a few extra minutes to take someone’s blood pressure and to do a prick-based blood glucose level check for those at high-risk.”

— Shifalika Goenka, professor at the Public Health Foundation of India

However, he stressed that adequate training and monitoring would be key if ASHAs — who have no formal medical training — are to succeed.

“We really need to find solutions which use existing resources more efficiently and allow us to provide basic care,” he said.

Experts credit India’s progress in reducing its maternal and child mortality to ASHAs who have played a fundamental role in increasing safe deliveries, breastfeeding, and vaccination rates. As a result, some argue that with declining fertility rates and a reduction in maternal and child mortality, that now is the time for ASHAs’ work to be broadened and updated to reflect the disease shift.

Shifalika Goenka, additional professor at the Public Health Foundation of India focused on NCD prevention, said that ASHAs should be trained to play an integrated role, including health, health promotion, early diagnosis, and disease prevention — much like a general practitioner.

“When an ASHA is at a home for a visit, it only takes a few extra minutes to take someone’s blood pressure and to do a prick-based blood glucose level check for those at high-risk,” she said.

She envisions ASHAs using a tablet-based system where the questions are automated with prompts. For example: Are you experiencing a loss of weight? Do you regularly feel dizzy? The results would be sent to the closest primary health care center and the tablet wouldn’t need an internet connection. This tablet-based support system is already functional in three states across India for assessing mental health, diabetes, and kidney disease.

Lack of qualified health care workers

But while experts agree that NCD screening and prevention efforts must be improved, some doubt whether ASHA workers have the necessary skills to provide such services.

“We need to understand that ASHAs were never meant to be a service provider. [They were] always meant to be a social mobilizer,” said Gauri Singh, principal secretary for public health and family welfare in the northern Indian state of Madhya Pradesh. “It's not something you want to have an ASHA do since she can come up with all kinds of results.”

Singh is particularly concerned that incorrect results could scare the community away. Some are also concerned that putting NCD prevention and management on ASHAs is not only unfair, but it’s not the solution. In some parts of India, ASHAs cover far more than their designated 1,000 population because there are not enough workers.

“There's a risk that ASHA workers might get overburdened,” said Raman Kumar, president of the Academy of Family Physicians of India, adding that this is particularly true in the states that still record high maternal mortality and morbidity. “There’s already a lot of discontentment among themselves about whether we can leave everything to ASHAs.”

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Instead, Kumar said the real issue was a lack of trained doctors in India who were willing to work in rural and remote areas. This, he said, fueled the discussion around the need for ASHAs to fill the gap.

“What functions will ASHA workers perform when it comes to NCDs? What about when doctors are available in communities? What are their roles? We have to get some coherent linkages.”

Kumar’s concerns echo what researchers at the George Institute of Global Health found when studying ASHAs: Many reported that the incentives provided by the government were inadequate and usually delayed. Many, the researchers found, wanted to actually be part of the health system and receive a regular salary rather than work on incentives.

Remuneration concerns

While ASHAs work for small incentives, this leads to the question: How do you actually measure prevention? How would ASHAs be remunerated for NCD prevention and management?

“We keep using them and don't pay them, which is not good,” said Singh.

One potential solution could be to pay ASHAs per door-to-door visit they make. This would be recorded on a tablet, which is already happening in some other states. “It is much more than screening, it’s also about raising awareness,” he added.

Maulik agreed, but he added that with an increasing workload for ASHA workers, fair and transparent remuneration would become even more important. Equally important, he said, is providing a supportive work environment for ASHAs, in addition to adequate supervision and assistance from managers inside the system.

Given the predicted loss that India faces, due to the burden of NCDs, investing in ASHAs may not be a panacea to the country’s health problems. However, sufficiently incentivizing them to provide quality community care may just be India’s most cost-effective way to instigate change and improve health outcomes.

“If you incentivize ASHAs or not is up to you. But if you want them to work, you probably should,” Maulik said.

For more coverage of NCDs, visit the Taking the Pulse series here.

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    Martin Bader

    Martin Bader is a journalist based in South Asia focused on human rights and development. He was previously based in the Middle East and writes in English and German.