Varshini Cherukupalli and Manisha Bhatia are third-year medical students at Northwestern University and Texas Tech University. Here they share their perspectives working for the last two years on a global health research project with Accredited Social Health Activists (ASHA’s) in Nanakpur, India.
As the lead community health worker in the rural area of Nanakpur, Haryana, India, Kiran Didi is irreplaceable. She devotes herself to her community by assisting in antenatal care, tending to newborns, and providing preventative health services to families. At the end of her busy days, she comes home to take care of her own family and household. In spite of meagre compensation for her work, Kiran Di competently manages her multiple responsibilities while never losing sight of her goal: to facilitate the improvement of the Nanakpur community’s health.
Kiran Di is an ASHA, or an Accredited Social Health Activist. In Hindi, asha means hope; that is exactly what ASHAs provide for their communities. The ASHA program was launched in 2005 by the Indian government’s National Rural Health Mission to address the challenges of limited access to healthcare facilities and inadequate infrastructure to effectively treat the population.
The program aims to connect the community members to government health facilities by assigning one female ASHA to every 1000 people in rural India. Nearly 850,000 ASHAs have been trained across India to provide antenatal and postnatal care, family planning awareness, sanitation and hygiene education, iron and folic acid supplements, and referrals of malnourished patients to the nearby Primary Health Center (PHC).
Government training supplies ASHAs with the medical knowledge to act as health workers, but it is their community roots that motivate them to be advocates for their villages. As Kiran Di says, “It is easy to identify a problem; the difficulty lies in convincing people to find a solution to the problem that is not Kam Chalao, or temporary.”
During the summer of 2015, we completed a community-based needs assessment to evaluate Nanakpur’s surgical disease burden. Our research would have been impossible without the help of Nanakpur’s ASHAs, especially Kiran Di. During the period of our study, the ASHAs introduced us to the community and even explained the purpose of our research to the villagers. Their support eased our integration into the community as we conducted our surveys. Because the villagers trusted their ASHAs, they accepted us and our probing questions without hesitation.
Even when they were helping us around the village, the ASHAs continued their regular community health duties while sharing anecdotes about their work with us. Sanjeevani, a Nanakpur ASHA, proudly shared that the pregnant women in her village had solely hospital deliveries for the past five years, as opposed to home deliveries. At the conception of the ASHA program, only 35.7% of Haryana deliveries were in the hospital; however, according to the 2015 National Family Health Survey, 80.5% of Haryana deliveries are now in the hospital. Sanjeevani is just one of the 90% “functional” ASHAs who have promoted institutional deliveries, thus making childbirth a safe process for millions of women in India.
The ASHAs are deeply committed to their communities, but they are made acutely aware of the financial difficulties they face. Many of the women train as an ASHA to supplement their household income. Unfortunately, the ASHAs are not salaried government employees; rather, they are paid for each service they provide under the Janani Suraksha Yojana scheme.
Since there is no set budget for the ASHAs in the state’s finances, the ASHAs receive payment each month only AFTER the state governments balance their budget. In some months this amounts to the ASHAs not receiving any payment at all. Furthermore, the ASHAs are rarely reimbursed for transportation of antenatal women to health care facilities, a task that is often undertaken by an ASHA out of her own pocket. Such delays and omission in payments affect the ASHAs’ family dynamics, as family members are less likely to be supportive if the additional income for daily cost of living is not received in a timely manner. So, even though the ASHAs take pride in their role as community health workers, they need compensation in a timely manner for their work to be sustainable, as well as for their family members to be supportive their work.
In spite of these financial difficulties, ASHAs continue to operate on goodwill as they realize the necessity of their role. As Kiran Di enthusiastically claimed, “Indian women are strong” and remain committed to improving their community. Enabling women to be economic and health representatives leads to greater investment within the community and a more inspired future generation. As such, ASHAs must be adequately compensated. To improve the health in a country, we must empower its women.
Varshini Cherukupalli is a third year medical student at Northwestern University Feinberg School of Medicine. Her interests lie in improving access to surgery globally and advocating for community health worker systems.
Manisha Bhatia is a third year medical student at Texas Tech University Health Science Center. Her passion for global health stems from empowering the individual to help the community.