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Applauding the ASHA for her contribution in COVID 19

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By: Dr. Ashish Bhat/ Dr. Swati Bakshi

COVID-19 has unleashed a devastating second wave in India. Currently, India is the most affected country in the world which is hit by the pandemic. So, while many of us have shifted to the work from home regimen, there are many who are still standing out there, tenacious and strong-willed, protecting the country from the forefront. All of us do recognize the contribution of doctors, nurses and other paramedical staff in fighting the pandemic, but somewhere we have missed out a very significant and imperative link that connects the community to the health system. Let us also give a headspace to those who are responsible for the last mile delivery- the ASHA workers.

Sixteen years ago, in 2005, when the ASHA was introduced into India’s health care system, as part of the National Rural Health Mission, it was a tentative beginning – only the states referred to as Empowered Action Group, now known as the “high focus states” of Bihar, Uttar Pradesh, Madhya Pradesh, Rajasthan, Jharkhand, Rajasthan, Odisha, Chhattisgarh, the North-Eastern states, and the hilly states of Uttarakhand, Himachal Pradesh and Jammu & Kashmir, and the tribal areas of a few states, were eligible. Barely four years later, in 2009, most of the remaining states opted to select an ASHA, including the state of Kerala, where the role of ASHA in the COVID response is a story that has been told and retold since the pandemic broke last year in January, 2020.

The ASHA, a cadre of nearly a million women, combining the roles of activist/social mobilizer, community care provider and link worker, are present in nearly every village/hamlet and urban slum of the country. Their core responsibilities such as distributing iron tablets, checking on immunisation schedules of babies and pregnant women, undertaking periodic checks on tuberculosis (TB) patients, among others, have been supplemented with additional duties of contract tracing, spreading awareness on prevention of Covid

The day to day work of the ASHA is the nuts and bolts of the work of the health system- for a system that ends at the lowest facility- the Sub Health Centre, now being transformed to the Health and Wellness Centres, under Ayushman Bharat, the ASHA represents a crucial community link -she knows her community and this knowledge has enabled the last mile delivery of health care and intensive involvement in COVID and non COVID related services.

The central and salient feature of the ASHA programme is its maturity, reached through a combination of local innovation, translated into policy articulation and programmatic action. ASHAs have built up social capital over the years and exercised their agency in a myriad ways. This is a programme where individual motivation and agency joined forces with a conscious collective solidarity to find expression in the ASHA’s response to the ongoing COVID 19 pandemic.

It is no exaggeration to say that notwithstanding a widespread network of health facilities, it is the presence of an ASHA in every village that enables nearly universal reach, as we have seen in these past few weeks. The urban ASHA launched in 2013 as part of the National Urban Health Mission, also mandates that an ASHA be selected from slum and slum like habitations to serve the needs of the urban poor, is evolving to the level of the rural ASHA programme.

From house to house surveys, to hand washing demonstration, sewing and distributing masks, and now undertaking community surveillance, ASHAs are at the forefront of the response to COVID in their communities. In addition to COVID 19 activities, ASHAs have not neglected their responsibilities for non COVID related essential care. They continue to support the health system in the delivery of essential services for mothers and children, for those with TB, and people with chronic diseases. Her pre-existing relationship in the community enables her to reach out to the community, including convincing women about the need to access safe delivery or to ensure vaccination for themselves and their children when services were resumed. ASHAs in several states continue to undertake home visits for palliative care, visiting the elderly, and her regular task of home visit for the new-born, home based young child care, and providing support and counseling to the pregnant woman or lactating mother.

From delivering drinking water to those in-home quarantined in Meghalaya’s villages, to ensuring home based new-born care in Rajasthan, or distributing medicines for chronic diseases in Jammu and Kashmir, ASHAs have reaffirmed that they are the face of the health system in the eyes of the community. In many states ASHAs are part of the block and district COVID response teams, giving them a high level of credibility and commensurate responsibility.

There have been arguments that engaging the ASHA in COVID 19 efforts would be risky, and they should limit their activities to raising awareness in the community. There have been instances of violence against ASHA and other health workers, often invoked by fear, but equally there has been swift action by states to address this and assure ASHAs of safety.

The government has taken legal action to address violence against all Health Care workers, including ASHA, by enacting an Ordinance under the Epidemic Disease (Ordinance) Act in May. Repeated reminders to states to ensure that masks and other protective equipment are provided to ASHA have also yielded results. Adding additional incentives for the ASHA, ensuring that other incentives are paid on time, and including her in the PM’s insurance scheme for COVID have been a small acknowledgement of the country to the invaluable support and unstinting commitment of the ASHA.

Applauding the efforts of the ASHA in supporting the health system during the pandemic is critical. Like all reforms, the ASHA programme too has challenges, and has produced variable and uneven effects across the country.  Nonetheless it is incumbent upon the health system to strengthen and sustain the ASHA. Enhancing her credibility and dignity, ensuring her safety and protection, building her capacity and by appropriately remunerating her efforts, all these surely need to be done.

  • Ashish Bhat is a public health professional and an alumni of the prestigious Tata Institute of Social Sciences, Mumbai. Currently he is working as a Senior consultant in the Ministry of Health and Family Welfare, GOI.Dr. Swati  Bakshi who is also a public health professional, an alumni of Tata Institute of Social Sciences, Mumbai  and currently working as a National Program Manager for ARMMAN (Developmental Organization working on Reproductive, Maternal and Child Health).

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