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The ASHA in the NRHM as para- health worker

Health is a dynamic process, involving constant adjustments and adaptations to the changing environment (internal and external). As the preamble to the constitution of WHO defines it, "health is a state of complete physical, mental and social wellbeing and not merely an absence of disease or infirmity". The WHO and the UN through the universal declaration of human rights affirm that health is a fundamental right of every individual. The Alma Ata declaration (1978) reaffirms that attainment of positive health is a fundamental human right and re stresses that the governments of all countries should work towards the development of health of their people

Health on one hand a highly personal responsibility and on the other a major public concern [1]. Since health of an individual is not only determined by the genetic constitution of the person but also the environment in which he grows, any individual effort to maintain a healthy state will not be successful unless it is supported with the organizational and legal infrastructure conducive to health in the community. It is here that political will and the government's responsibility towards health comes into play.

The constitution of India, through the directive principles provides that health is a State responsibility. There is a mention that the State has the duties of improving the nutritional status and living standards of its people and improving public health.

Despite the constitutional directives to the State, the health condition of a majority of Indians and healthcare services system is very poor. The reason for this is often stated as the inadequate public spending in the healthcare sector. At a 0.9% of the total of 5.2% of the GDP spent on healthcare India ranks amongst the lowest (WHO report). But what poses more as a problem is that healthcare facilities that are available, are concentrated in the cities where only 27.8% of India's population lives. The healthcare infrastructure rural India is either nonexistent or in a very poor state (wherever it exists). This urban rural divide due to the unequal distribution of health services leaves a large proportion of needy and vulnerable people helpless. The prime minister of India, confessed the grim state of the nation's health at the launch of NRHM, "We have grievously erred in the design of many of our health programs. We have created a delivery model that fragments resources and dissipate energies. Most importantly, we have paid inadequate attention to the public health issues"[2].

To even out the urban rural health divide and to realise its obligation to the Alma Ata, to make health care services universally available the UPA government introduced the concept of the National Rural Health Mission in September 2004. NRHM was launched throughout the country for a period of seven years (2005-2012) on 12th April 2005. The program gives special attention to 18 states with poor health indicators and/ or infrastructure. These states are Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu and Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttarakhand and Uttar Pradesh. Under NRHM various vertical health programmes (like national vector borne disease control programmes, health and family welfare programmes, national AIDS control programme and revised national tuberculosis control programme ) were integrated at the district level.

The main objective of the NRHM was universal availability of "primary health care" or the essential healthcare. The NRHM proposed developing of a new cadre of community health worker - ASHA, an acronym for Accredited Social Health Activist. ASHA would play a key role in the NRHM by serving as a crucial link between the village community and the heath centre. By the 2012, the NRHM targets to train 4,00,000 ASHAs. 7.36 lakh ASHAs have been selected, 4.58 lakh trained and 4.95 lakh provided with drugs kits [3].

ASHA is a resident woman of the village with formal education at least up to the 8th standard. She is selected by the Gram Sabha and is accountable to the village Panchayat, the general norm of selection is one ASHA per 1000 population. The ASHA is also expected to work with the Aganwadi workers (AWW) to conduct various health activities within the village. The AWW is a mentor to ASHA.

ASHA will "....create awareness on health and its social determinants and mobilize the community towards local health planning and increased utilization and accountability of the existing health services. She would be a promoter of good health practices"[4]. After appropriate training ASHA would be able to advise the community about nutrition, hygiene and sanitation, contraception, mobilize the community, inform them about the various health services available in their village and emphasize the appropriate use of the same. She would also counsel women on the importance of safe institutional deliveries and new born care, importance of breast feeding, immunisation and prevention of infection. In addition to the activities already mentioned, ASHA is the provider of DOTS. Each ASHA would be provided with a drug kit containing all essential drugs including AYUSH drugs, ORS, iron and folic acid tablets, chloroquine and contraceptives.

Dr Shyam Ashtekar, of Bharat Vaidyaka Sanstha (Nashik based NGO) says, "With proper care and management, ASHAs can increase access to healthcare, ensure early relief and less damage, boost preventive health, reduce the burden of hospitals, decrease unit costs of healthcare, reduce transport costs on healthcare and drug-expenses."[13]

The NRHM objective of reducing IMR is already on its way, since the introduction of the programme, the IMR has fallen by 4 points to 53 in 2008, the institutional deliveries increased in almost all low performing states with the subsequent lowering of the maternal deaths, so have the states been able to increase the percentages of full immunization [3]. All these gains can be partly attributed to the successful appointment and work of ASHA in most of the states. ASHA has brought about a meaningful change in the Reproductive and Child Health (RCH) across the country. ASHAs can play inevitable role in identifying the health needs of the community they come from, thus giving valuable insights in the micro planning of a health programme.

This Common Review Mission (CRM) set up as part of the Mission Steering Group's mandate of review and concurrent evaluation under the MOHFW conducted its appraisal in November 2007 [*]. It mentions about the increased utilization of healthcare services and success of the Janani Suraksha Yojana (JSY). According to the report ASHA programme has received cooperation from the community; reason for this is that ASHA is selected from within the community. In most states, the Panchayat is actively involved in selection of ASHA.

ASHA are improving the health of the people of north eastern states especially Assam especially in the area of immunisation along with ANMs. For the further development of ASHAs, Radio programmes are broadcasted on All India Radio, twice a week, providing health education information to them. Mobile phone connections have been given to ASHA so that she can give feedbacks.

In Bihar, ASHA programme is responsible for improvement of health through Village Sanitation Committee.

But despite of these success stories of the ASHA programme, there are a few criticisms. One which is majorly encountered in most of the states is that there is no clear division of role that ASHA has to play. This confusion is amongst the health care providers like the doctors, nurses and the AWWs who consider her as a mere assistant or attendant. This is not the first time that CHW like ASHA have been introduced. Village Health Guides (launched in 1978) were to play a role similar to ASHA in the community but fuzzy role definitions, lack of training and implementation lead and concentration on curative health aspects led to the failure of the programme. The VHGs were seen as subservient by the healthcare personnel. The ASHA model has been developed after studying the faults in VHG model but still her role is ambiguous which may overburden her.

Another major concern is that since ASHA is an honorary volunteer, she does not draw any salary. She is given incentives on per piece basis under provision of services like DOTS, JSY. Her efforts towards the community health are also recognised non-monetarily by giving awards for excellent service. Such a provision was thought to increase the accountability of these women but many writers call for the need to give ASHA a reasonable sum to support herself and her family so that she is motivated to work better. The untied fund of Rs 10,000 provided to every village under NRHM can be used at the discretion of the Sarpanch and ANM to compensate the work done by ASHA. But since the funds given to a village to conduct various health activities are very less, this untied fund is used up to carry out those activities. The success of the JSY scheme under the NRHM is because ASHAs have concentrated on institutional deliveries because of the incentive involved. It has been criticised that the disproportionately high compensation just to escort the pregnant women to the nearest health centre has led to the ASHA ignoring her other duties.

Currently ASHA are activist and not full time health workers and have flexible work times, but there have been demands from the ASHAs themselves for employment. This demand for employment has gained momentum after the ASHAs have realised that they are able to shoulder the current responsibilities and are ready to take up a full time health job. Regularizing ASHAs with a fixed salary will make them more accountable and their work can be monitored.

The training programme of ASHAs should make appropriate adaptations depending upon the health problems faced by the community. Repeated efforts should be undertaken to keep ASHAs updated with newer information related with health and health related behaviour. The quality and content of such training programmes need to be assessed. Appropriate training methods and media should be employed. There have been reports that during training programmes, study materials available especially those in the native language of the community are not sufficiently available. The training of ASHA should be foolproof since in the remotest of the Indian village she is often the only health care provider (other than the traditional healers) available and with adequate training can manage common illnesses particularly childhood illnesses [1].

The ASHA under NRHM is provided with drug kits containing medicines for common diseases like fevers, diarrhoeas etc. But in many places ASHA received their kits of essential drugs late and so was the replenishment of the drugs not done in time as facilities for such did not exist. There is still ongoing debate about ASHA's right of prescribing medicines. But ASHA holding basic and commonly used medicines in a remote village (often without any doctor or pharmacy available round the clock) will only help in managing an illness till medical assistance available. In this regard however ASHA will have to be thoroughly trained about the medication she might have to prescribe.

Another issue with the programme is that of attrition. ASHA is introduced into the community after a rigorous selection and training process. The induction training is of 23 days spread over a year, also there are various additional programs conducted by the individual states if need arises. Thus it is important to plan about what happens if ASHA leaves the system. The time to select a replacement will be substantial; in this regard also a fixed salary will lower attrition rates.

The CRM report mentions about delays in the payment made to ASHAs in villages of Bihar. Also in Bihar the training of ASHA is lagging behind other states, where the 4th module of training had begun [5].

In Madhya Pradesh flexibilities under the selection and training of ASHA in tribal areas have not been fully implemented [CRM report].

Selection of ASHAs has also come under scrutiny, in some villages the kin of the village headmen or other power holders are selected over other deserving candidates. Also in a country like India where the literacy levels are poor, even more among rural women, it may be difficult to find women with the basic standard 8th education for selection as ASHA. When this difficulty is encountered, whether the norm of basic education level can be relaxed is an issue which needs to be studied. After all it has been observed that even an illiterate dai (traditional birth attendant) with adequate training can conduct safe deliveries.

The NRHM programme through its visionary- ASHA is a great step towards realization of the 'health for all' dream. But the success of programmes such as ASHA depends upon the performance of the health workers. It is therefore necessary that ASHA are equipped to provide preventive, promotive and curative (for common ailments) health service. Only those with leadership skills and flair to work with the community should be shortlisted. Last but not the least an effective system to monitor the work done by the ASHA should be put in place.

References

1. K. Park, Park's textbook of Preventive and Social Medicine, 19th edition

2. C. Lahariya, H. Khandekar, J. G. Prasuna & Meenakshi : A critical review of National Rural Health Mission in India . The Internet Journal of Health. 2007 Volume 6 Number 1

3. http://www.mohfw.nic.in/NRHM/Documents/NRHM_The_Progress_so_far.pdf

4. http://www.mohfw.nic.in/eag/accredited_social_health_activis.htm

5. NRHM-common review mission (draft), Ministry of Health & Family Welfare Government of India, Nirman Bhawan, New Delhi.

6. Arun Kumar Sharma, National Rural Health Mission: Time to Take Stock, Indian Journal of Community Medicine / Vol 34 / Issue 3 / July 2009

7. http://www.cbgaindia.org/publications/featured_articles/An%20Assessment%20of%20UPA-I%20through%20%20%20%20a%20Gender%20Budgeting%20Lens.pdf

8. Garg S, Nath A. Current status of national rural health mission. Indian Journal of Community Medicine 2007;32:171-2

9. T.K. RAJALAKSHMI, The second National Health Assembly, in Bhopal, criticises the NRHM and the government's health care priorities, Frontline Vol. 24, issue 7,29 April 2007, http://www.hinduonnet.com/thehindu/thscrip/print.pl?file=20070420001304800.htm&date=fl2407/&prd=fline&

10. Tarun Seem, Public Sector Reform and Rural health workers Country Paper - India, http://www.aaahrh.org/2nd_Conf_2007/Cases/IndiaTarun%20Seem%20Public%20Sector%20Reform.doc

11. Alma Ata Declaration, http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf

12. S. Goel : From Bhore Committee to National Rural Health Mission: A Critical ReviewThe Internet Journal of Health. 2008 Volume 7 Number 1

13. http://www.expresshealthcaremgmt.com/20050515/focus01.shtml