The Foot Soldiers of India’s Public Health System: A Glimmer of Hope

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By Bhavani Giddu, CEO, Footprint Global Communications, New Delhi—

“I was a nobody in my community. I was married off right after I finished tenth grade, and had two children. My life centered around my family and domestic work, until someone introduced me to the community of ASHAs (Accredited Social Health Workers). I took a risk and enrolled myself in the public health program that trained and equipped me with knowledge about newborn and maternal healthcare. Today, thanks to the difference I am making in and around my community, I have newfound respect and recognition.”– Sonali Shinde, ASHA in the State of Maharashtra, India.

Sonali’s testimonial about the life of an ASHA should resonate with hundreds of thousands of health workers across India. Pioneered by the Indian Ministry of Health and Family Welfare (MoHFW) in 2005, these social health workers are the frontline foot soldiers of the public health delivery system.

For most of us living in the urban areas in developing and developed nations, information is something that is too often taken for granted. All we have to do is pick up our phones and speak to the almighty Google to locate the information we need, and voila! We become experts on something we barely had any knowledge about until ten seconds prior.

In remote and marginalized areas of India, however, the situation is very different. Many women get their health information from lore and myths perpetuated by familial and social traditions. This often prevents women from visiting a public health facility to seek healthcare services. Instead they rely on home remedies, or worse, seek the services of illegitimate or untrained practitioners or quacks.

This can have serious consequences for pregnant mothers, who too often receive poor nutrition and healthcare during pregnancy. Many expectant mothers are not aware of the free pre-natal check-ups available at public health centers. During birth, many women rely on untrained midwives to deliver their babies at home rather than going to a hospital. Myths and lack of awareness about the folic acid tablets that are distributed for free at government facilities result in women becoming anemic.

All of this contributes to high maternal and infant mortality rates. The maternal mortality rate in India stands at 167[1] per 100,000 live births, while the infant mortality rate is 40[2] per 1000 live births. In contrast, the US maternal mortality hovers around 25 deaths per 100,000 births, and infant mortality is approximately 6 per 1000.

An ASHA’s role is to overcome these significant challenges. Today, there are more than 870,000[3] ASHAs in rural India, working tirelessly to enhance reproductive, child, and maternal health in their communities and villages. They are mostly women, and men in small numbers, who have completed a middle school education or higher, and are chosen and trained by the government through a rigorous process involving community and self-help groups, district officers, and village councils.

ASHAs are ingrained into the public health system at the grassroots level. They focus on villages and rural areas that are underserved due to a severe paucity of adequate medical practitioners and health centers. They are locally chosen by the government and NGOs to play the role of health educators and facilitators.

An ASHA is responsible for the health of a woman during her gestation period and delivery, when she breastfeeds her newborn within an hour of birth, and when her child needs immunizations. In addition, ASHAs play an integral part in educating young couples on family planning, spacing methods, and the availability and importance of contraception, especially new and safe methods like injectable contraceptives introduced recently in India.

This family planning work is essential in a country with a burgeoning population and too many illegal and unsafe abortions resulting from unwanted pregnancies. The Indian fertility rate, currently at 2.3[4] births per woman, needs to be addressed especially in densely populated states like Bihar. It is here that the role of an ASHA becomes critical – to make sure women across the nation are uniformly informed, and empowered with a basket of choices.

The wellbeing of Indian families is up to these foot soldiers. Having personally seen the work of ASHAs in many states across India, I know that they inspire people through their motivation and undying passion, despite being underpaid and overworked. There is roughly one ASHA per 910 people, and their pay is sometimes as low as US $20 a month[5]. For each safe delivery of a baby, he/she is paid US$9.30, and for every child completing an immunization session and every person who goes through family planning education, a meager US$2.30 each.[6] ASHAs are often short of medical supply kits, and lack monetary and logistical support.

It will be ill-advised to take the ASHAs for granted – they are the backbone of India’s public health distribution system. ASHAs must be sustained with mentoring, skill-building, and incentive-based packages to keep them motivated. This will encourage them to provide end-to-end services by tracking, monitoring, and reporting the women in their communities to the healthcare system.

“The fact that I am underpaid does not demotivate me. I am proud of the fact that I am touching the lives of people, and when I start walking down the street, people recognize me and fondly call me ‘didi’ (elder sister). Until recently, I was the wife, daughter-in-law, and mother of someone else. Today, I am known by my name, for my work. Nothing beats this incredible sense of achievement,” wraps up Sonali.

The author, Bhavani Giddu (@bgiddu) is the CEO of Footprint Global Communications, a specialist public health advocacy communication agency based in New Delhi, India.







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