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The Role of ASHAs in Improving Maternal and Newborn Health: A Closer Look at India’s Community Health Worker Program

By: Sarah Hodin, Project Coordinator II, Women and Health Initiative, Harvard T.H. Chan School of Public Health

India’s Accredited Social Health Activist (ASHA) program was established by the National Rural Health Mission in 2010 with an aim to improve health outcomes—particularly among women and children—and to reduce geographic and socioeconomic disparities. ASHAs are recruited and trained to work in their own communities as health activists, educators and providers of basic essential services.

The ASHA’s role

Gopalan SS et al. Assessing community health workers’ performance motivation: A mixed-methods approach on India’s Accredited Social Health Activists (ASHA) programme. BMJ Open 2012; 2: e001557.

While ASHAs are not trained to provide comprehensive reproductive, maternal and newborn care, they have several important responsibilities within their communities including:

  • Identifying and registering new pregnancies, births and deaths
  • Mobilizing, counselling and supporting the community to demand and seek health services
  • Identifying, managing or referring cases of illness
  • Supporting health service delivery through home visits, first-aid and immunizations sessions
  • Maintaining data and participating in community-level health planning

Room for improvement

Evidence on the effectiveness of ASHAs in increasing maternal and newborn health care utilization and improving outcomes is mixed. While some studies have highlighted the potential of ASHAs to help lead community mobilization, reduce neonatal mortality, encourage adherence to antiretroviral therapy among HIV-positive women and increase immunization rates, substantial gaps related to knowledge of pre-eclampsia, promotion of institutional delivery, contraceptive counselling and assessment of obstetric danger signs have also been noted.

The impact of ASHAs on their communities is largely dependent on the quality of their training and other health system factors. Research has indicated inadequate health system support for ASHAs including a lack of strong supervision, limited opportunities for continuing education and training and poor workload management. There is also debate around the current financial incentive scheme for ASHAs and whether it is appropriate for the amount of work that they do, which has been shown to cause some ASHAs to feel overworked and less motivated to perform their tasks.

Voices from the field

Several challenges hindering ASHAs’ ability to perform their roles have been identified in various qualitative studies:

Lack of health system support

“ASHAs have not been trained the way they should be … They get limited training on community mobilization, child immunization and others due to which they have limited knowledge and skills … We are training ASHAs after recruitment rather than asking them to successfully complete a course to apply for this post. The assured job in hand decreases her motivation to learn new things in training.” – Health system representative [Source]

“The career path and promotions for [other health care workers] within their own departments are certain but not for ASHAs hence they are de-motivated.” – Health system representative [Source]

“There is no proper coordination between the supervisors and their instructions to the ASHAs and this results in leaving the task undone and de-motivates ASHAs to work.” – ASHA co-worker [Source]

Inadequate compensation

“I get my salary after 5–6 months. I am not satisfied with the salary. Many times, I wanted to leave this job, but every time my husband suggested me to continue this job. He said that something is better than nothing.” – ASHA [Source]

“My village is small; there are only few cases of pregnancy. I have limited income compared to villages with huge population.” – ASHA [Source]

“ASHAs’ have a list of work to perform… But since they have limited avenues to earn income, we mostly encourage them to achieve the targets like immunization, hospital delivery, organizing monthly village health nutrition day, etc.…, so that they could earn some money.” – Primary health care auxiliary nurse-midwife [Source]

Sociocultural factors and gender norms

“The elders say why waste money in going to hospital, they can deliver at home without any problem” – ASHA [Source]

“Since women have no representation in the village council and have little role in decision making with matters related to village; for ASHAs to initiate community action is not very feasible.” – Primary health care doctor [Source]

“I feel hesitation in talking with men. They get information from my husband as he knows a lot of things after going with me to meetings.” – ASHA [Source]

“Some women come to me and ask for measures to stop children. I tell them convince your husband first, otherwise if you do something on your own, your husband will say unnecessary things.” – ASHA [Source]

“People normally go to hospital only when there is complication or obstructed labor. It is traditional to give birth at home.” – ASHA [Source]

Poor infrastructure and quality of facility-based care

“Remote villages have poor roads and may take about 5 hours to reach on foot. ASHAs maintain health records of the village; it saves time for the nurse in identification of pregnant women, children and sick people.” – Primary health care doctor [Source]

“They go to the hospital after I remind them to go on the Wednesday. Then they come back to me and say, ‘You are a liar, they do not have medication.’” – ASHA [Source]

“We explain to patients that if you deliver your child in the hospital you will get better care. Upon their request, we stay with them, even at night. But when after all this effort someone raises their voice at us in front of the patient and says keep quiet, mind your own business and do not talk useless nonsense, then it is hurtful and humiliating.” – ASHA [Source]

Hope for the future

Despite these challenges, being an ASHA can also be incredibly rewarding:

“Prior to being an ASHA I didn’t go anywhere alone. But now I can move about freely. I accompany my patients to facilities. After being ASHA my confidence has increased.” – ASHA [Source]

“Earlier no one knew us. Now since she became an ASHA the honor and respect of the family has increased…Earlier no one asked our opinion. But now everyone takes the view from our family.” – ASHA [Source]

ASHAs are uniquely positioned to reduce health disparities by serving the health needs of their own rural communities. With additional research, policy and programmatic efforts, India’s health system can support ASHAs to fulfill their potential as change-agents in improving maternal and newborn health.

Learn more about community health workers and maternal health.

Read other posts from the Global Maternal Health Workforce blog series.

Access resources related to the global maternal health workforce.

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