Rethinking ASHA: The Frontline of India’s Maternal Health

India’s National Rural Health Mission was launched in 2005 with the goal to “improve the availability of and access to quality health care by people, especially for those residing in rural areas, the poor, women and children.” With the ASHA (Accredited Social Health Activist) program, the country has been making remarkable strides in the improvement of women’s and maternal health.

The ASHA Program works by providing every village in India with a trained female community health activist volunteer.  Each of these community health workers, referred to as ASHAs, are between the ages of 24-45 and literate, with a minimum level of 8 years of formal education. Then, each ASHA undergoes regular training and continuing education. This enables them to empower women in their own communities to make healthy decisions and understand determinants of health, such as nutrition, and sanitation and hygiene.  The ASHAs are also able to connect community members to existing services, which promotes timely use of those services.

The health focus for ASHAs is diverse but all related to women’s health and maternal health.  For example, each ASHA is adequately prepared to provide advice on labor and delivery, breast-feeding, immunizations, contraception, prevention of common infections, and care for newborns and young children. These community health advisors are also a resource for tangible items like oral rehydration therapy (ORT), iron folic acid tablets, and contraceptive materials, items that are invaluable to newborn and child health, maternal health, and family planning methods.

Maternal and newborn health indicators in India are not nearly low enough to achieve national or global targets.  According to an interagency report named Trends in Maternal Mortality: 1990 to 2008, in 358,000 maternal deaths occurred in 2008; 99% of those occurred in developing countries, and more than 17% of maternal deaths took place in India.

Although each ASHA is working on a volunteer basis, there are incentives for positive health indicators. For example, for each woman who delivers a child in a hospital, the ASHA is reimbursed 600 Rupees ($11.70 USD); the mother who delivers at a hospital is reimbursed 1400 Rupees ($27.30 USD). There are also incentives for getting children timely and complete immunization.

Despite the Indian Government’s touting of the program successes, there are many who argue that the ASHA program needs to be improved. For example, studies have found that ASHAs are not being chosen based on specified criteria, and may therefore not be fully qualified to serve that function. The quality and training levels of ASHAs is also not up to standards; this leads to unsatisfactory knowledge of health issues, incomplete understanding of job functions, and other problems. Even the concept of providing financial incentives has been shown to be problematic in some cases.  However, there are clear suggestions for how to improve the program and therefore the health outcomes of women all over India.

For example, more complete training would provide a greater sense and understanding of responsibilities, roles, and value in the community. It would also provide for higher level of knowledge related to maternal health, newborn heath, and related issues. To further enforce stronger baseline knowledge, potential ASHAs should be tested for their knowledge on maternal and child health needs. Innovations have been seen in some parts of India for their ASHAs, such as ASHA radio. This has been a creative way to provide a sort of job training. Finally, recognizing ASHAs and giving them a greater role in activism, advocacy, and giving them some kind of public certification would provide them with greater recognition in their communities.

There is immense potential for success in this project. Many countries, including Iran, have seen great successes in their community health worker programs.  They have instituted strong training programs, regular reviews of their programs, and choose qualified community health workers.

These suggestions could all bring more credibility and legitimacy to India’s ASHA program, and bring the country closer to it’s target for decreased maternal deaths.

Flickr photographs via DFID (photo 1, photo 2)

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  1. […] or ASHAs (Accredited Social Health Activists). There are those who say that the ASHA program needs to be improved in terms of how ASHAs are selected, trained and rewarded. There’s certainly no arguing that a […]

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