Incentivise health workers on the ground
There are two positives from the Covid-19 pandemic. One, there is growing realisation of the need to invest in primary health, and second, there is recognition of the invaluable role of Accredited Social Health Activist (Asha) workers at the grassroots. Their performance in the face of all odds should force the government to think about how to strengthen this cadre and make it more effective in delivering grassroots health care. One initiative should be to induct more male health workers into the system. This is the time to make community health work more attractive for all genders.
To begin with, the incentive structure must change. India has 900,000 Asha workers who get an honorarium of ₹2,000 to ₹4,000, depending on the state government. They get minor incentives for recurring tasks, with each worker being responsible for up to 2,500 people in her district.
They need to be given post-retirement benefits and other incentives if India is to build on this crucial cadre. The pandemic may recede, but a host of health care issues have to be dealt with. Instead of piecemeal payments linked to tasks, there must be a drastic overhaul in their pay structure. A non-governmental organisation (NGO) worker in the field told me that the government’s logic in some states is that taskbased incentives keep the Asha worker on her toes. This is the wrong approach. Even if the remuneration is called an honorarium rather than a salary, state governments must now consider providing Asha workers with the job security that other medical professionals get.
During the pandemic, many were given a very short period of training on how to handle the deadly virus and its aftermath. Their workload increased drastically without commensurate infrastructure. Yet, they have come up trumps. This calls for creative strategies to better their lot.
Another area that needs re-evaluation is career progression. Through the Skill India programme, Asha workers should be given the opportunity to move to the next level in health care, should they so chose to. There should be year-round training for them in rural settings and much greater engagement with them to ascertain their personal aspirations for professional growth. One noteworthy step has been the commitment of the National Health Mission to pay the fees for Asha workers who wish to complete their secondary education through the open school system and for them to be given preference in admissions to nursing schools.
They should also be given access to information about institutions where they can further their skills and avenues of employment open to them. Through the panchayat system, there should be community recognition of their efforts; something which could encourage more people, and hopefully men as well, to join the grassroots health care system. Their requirements such as crèches for their children, overnight rest rooms, sanitation facilities and safety must all get priority now. They must also have access to proper grievance redressal forums.
If the right inputs are made into the Asha system now, it can have the potential to change and improve health care at the grassroots level and also eventually correct gender inequalities in the communities they function in. Much will depend on the respect, recognition and rewards that both the central and state governments afford them for their role in holding together a rickety grassroots health care system in a most challenging time.