ASHAs are crucial for reaching out interiors: here are suggestions to help them better serve the community
Aditya Singh and Shivani Singh | April 11, 2020
COVID-19, the virus that began its world tour from a city in central China, has spread around the planet. As of April 11, this pandemic has caused over 1.6 million cases and the death toll as crossed the 1,00,000 mark. In the absence of any vaccine, the health systems around the world are struggling to contain this pandemic. While the efforts to develop a vaccine for this virus are on, the experts have warned time and again that it might take several months before the vaccine is ready for use. This clearly indicates that the virus is not going to go away soon and the health systems will have to be ready to deal with a flurry of COVID-19 patients in future as well.
In India, the past two-three weeks have witnessed a rapid surge in the number of COVID-19 patients and associated deaths. Although the spread of pandemic still seems to be limited to urban areas, it is anticipated that it would eventually spill over to the rural areas of the country where almost two-third of the population lives. Once it spreads to rural areas, it would be very difficult for the government to cope with it, primarily because the public health system in rural areas is utterly dysfunctional and ineffective.
The rural healthcare system, which consists of community health centres, primary health centres, and sub-health centres, has long been suffering from shortage of health workers, inadequate supply of medicines and instruments, and lack of basic amenities such as drinking water, toilets and electricity. What we do have in adequate quantity at the moment is a huge workforce of the Accredited Social Health Activists (ASHAs) who know our villages very well.
Evidence from around the world suggests that the frontline health workers have been critical in saving new-born lives, improving child nutrition, reducing the burden of AIDS, tuberculosis, and malaria. It has also been documented that if trained and mobilized strategically, the frontline health workers (FLHWs) have the potential to save lives during epidemics such as the one we are facing today. Whether it is Zika virus outbreak in Latin America or Ebola outbreak in Africa, or Nipah virus in Kerala, frontline health workers have always played a key role in reducing preventable deaths.
Since FLHWs belong to the communities they serve, they know the community very well and the community trusts them more than other health workers who do not visit the community that frequently. They can communicate with the families within the community much more effectively than other workers. This could be harnessed to spread awareness and contain the deluge of misinformation and rumours about the virus in our rural communities. They can be the source of local disease intelligence which can help health authorities detect, isolate, and treat people with the symptoms of the coronavirus. In the event of disease outbreak, they can stop people from turning to traditional healers and direct them to hospital where they can be properly cared for.
In the last two weeks, the Indian government has roped in ASHAs as well in its bid to stop or slow spread of the virus in rural areas. The state governments have directed ASHAs to make regular home visits, conduct household surveys to find out suspected cases, monitor them daily, report these cases to the block-level authorities, and spread awareness about the disease among community members.
However, ASHAs are facing a range of problems in performing their duties. First, they are preforming their duties without personal protection equipment (PPE), hand sanitizers/soaps, and masks. This not only exposes them to the risk of getting infected with the coronavirus but also puts additional financial burden on these health workers who are paid a miniscule amount in lieu of their services. Although the government has promised to provide an additional incentive of Rs 1,000 for their services during April and May, this does not seem to be adequate given the risks involved in their work.
Second, most ASHAs are yet to receive a proper training to handle coronavirus, despite the fact that the situation at the grassroots level is rapidly escalating and may become a serious challenge to our rural health system. The government should have started training its health workforce as early as February when the first case of the coronavirus infection was detected. However, both, the central and the state governments were in deep slumber and woke up only in the last week of March when the number of cases was rising much more rapidly than the previous week and the entire country was shut down for 21 days. Since it is not possible during the lockdown to conduct face-to-face training at block level, some state governments (for example, Madhya Pradesh) decided to train ASHAs though video conferencing. But it did not work for a great majority of ASHAs as they lacked necessary hardware (Android phone) to access the online training programme.
In this fight against the highly contagious virus, ASHA workers are not only prone to getting infected with this, but have also been facing denial, mistrust, harassment, and even violence from their own communities. Recent media reports from various states concur this. In Sadiq Palya locality of Bangalore, a mob of over 100 people not only assaulted the ASHA workers who were collecting data, but also snatched their mobile phones and bags. Similar incidents from Adilabad, Ratnagiri, and many other parts of the country have come to light. It is often the case that people do not let them in their house or stand at their doorstep as they fear that she might infect them.
While the work of doctors, nurses and other paramedics is being appreciated across print, electronic, and social media, the work of ASHAs remains invisible and unappreciated and their challenges and problems ignored by the outside world. In the wake of the fact that the discrimination, harassment and attacks on health workers are becoming more and more common, the government should ensure safety and security of ASHAs. We suggest that their contribution to this fight against the coronavirus should be acknowledged at national and state level as this would motivate ASHAs and help them in gaining trust and respect in the communities where they are serving. Providing a comprehensive and, if possible, hands-on trainings on COVID-19 to more and more ASHAs will further increase their confidence and they will be able to communicate better with the communities they are serving. The government should find ways to reach out to as many ASHAs as soon as possible. Additionally, they should be provided with protective gear and other essential equipment that would help them keep infections at bay. Making the most of our FLHWs at the grassroots level is the only way in which we can prevent the spread of this disease in rural India, and we need to make sure that they are well equipped and ready to fight this pandemic.
Aditya Singh holds a PhD in health and care professions from the University of Portsmouth (UK). He is currently working as an assistant professor of geography at Banaras Hindu University. Shivani Singh holds a PhD in economics and is currently working as a researcher at the Population Council, New Delhi.
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