ASHA – An Overstretched link

Author: Dr Ruchi Verma
Surveillance Medical Officer, World Health Organization
Adjunct Faculty, Global Village Foundation

ASHA stands for Accredited Social Health Activist and plays a pivotal role in NRHM for health care delivery in rural areas. The concept was born in China by the name of Barefoot doctors in 1950s, as a main play in primary health movement (Bajpai & Dholakia, 2011). The idea was further adopted by Bangladesh and later Iran in 1972 and 1979, respectively (Bajpai & Dholakia, 2011). The Alma-Ata declaration of 1978 highlighted the concept of community health workers to improve the starving primary heath care (Saprii, Richards, Kokho, & Theobald, 2015). The newly launched recommendation was quickly perceived by many countries and reaped the benefit. Iran launched the CHW framework in the form of Behadasht yar (female) & Behyraz (male) (Bajpai & Dholakia, 2011). Government of India adopted this after a long slumber, in 2005 with the birth of National Rural Health Mission (NRHM). (Government of India. Ministry of health and family welfare, n.d.)

Based on the concept of CHW, ASHAs were recruited through NRHM as incentive based community workers for community mobilization, enhancing awareness and as an important link between the community and the public health care. The main focus of their work has been on maternal and child health, the core pillars of a healthy society. ASHAs in most places have a minimum basic education of Tenth standard. However this criterion is relaxed in many places, in case of manpower shortage.

Inception of ASHA had the simple vision of strengthening the abysmal primary health care (PHC) through strong communication between members rooted in the same community (ASHAs). Although an excellent much needed step, the ever expanding healthcare needs of the inherently complex Indian society are burdening ASHAs and needs a serious thought.

ASHA has multitudes of general responsibilities roughly categorized into the following (PK, 2015):

  1. link worker/facilitator- for antenatal and postnatal care
  2. Community health worker– for immunization of children, treating simple ailments, birth registrations, promoting DOTS-TB referral and use of ORS & Zinc in diarrheal illnesses
  3. Social activist– community mobilization for civil rights, special focus on increasing awareness among marginalized sections of the community.

Since ASHA is working through multiple sectors governed by different bodies, it makes ASHA accountable for all those sectors. There are a few things to be kept in mind- the responsibilities of ASHA change with the focus of the government (state and central), with most lucrative incentives and the amount of work in each scheme. India accounts for 17% of the global maternal mortality and 21% of the global childhood deaths (PK, 2015). The GoI has two vertical programs targeting the above mentioned. First, Reproductive Maternal and Neonatal, Child Health (RMNCH) aims at holistic health of both the mother and the child, however, pivots at the maternal health for the success of the program. Second, the Expanded Programme on Immunization (EPI) targets maximal coverage and complete immunization of less than 3 year old children. Much of the health workforce functions are the same at the ground level. ASHA works for both the programmes along with Auxiliary Nurse Midwife (ANM) under the leadership of Medical officer at the PHC or Community Health Center (CHC). According to the requirements of the government (state, local) and the running programs, the priorities for ASHAs fluctuate constantly. In states like U.P where the immunization is wretched, the pressure from the administration to improve the same ultimately falls on the ground level workers like ASHAs.

Strengthening the primary health care system is a major focus, however the strategy towards that is blurry in terms of action. The need of the hour is to generate and build the capacity of ground zero workforce to comply with the persistently growing demand in primary health sector. There are two options for enhancing the quality of primary health delivery at the ground level- Firstly, a basic pay along with the incentives to reduce attrition and maintain the quality of work. Secondly, focus on refresher trainings by the medical officers and partner agencies UNICEF, WHO, etc. Finally, there is a need to curb irregularities in the financial pay out to the workforce.


  • Bajpai, N., & Dholakia, R. H. (2011). Improving the Performance of Accredited Social Health Activists in India, (1), 1–63.
  • Government of India. Ministry of health and family welfare. (n.d.). About Accredited Social Health Activist (ASHA).
  • PK, F. F. R. M. V. K. K. A. A. S. M. (2015). Assessment of “accredited social health activists”-a national community health volunteer scheme in Karnataka State,India. TT -. Journal of Health, Population, and Nutrition, 33(1),137–145.
  • Saprii, L., Richards, E., Kokho, P., & Theobald, S. (2015). Community health workers in rural India: analysing the opportunities and challenges Accredited Social Health Activists (ASHAs) face in realising their multiple roles. Human Resources for Health, 13(1), 95.