The last mile of India’s public health system is a women-led sector. This is a reality that is largely consistent across India and recognized by the world. In 2022, ASHA employees received one of six Global Health Leaders Awards at the 75th Global Health Assembly. Today, ASHA workers – the first access to basic health services at the village level – can be found across India’s villages, advocating for universal immunization, counseling on antenatal and postnatal care practices, home care for newborns, etc. Then there are the Anganwadi workers who, as the name suggests, are in charge of the Anganwadi Center – a unit of the Ministry of Women and Child Development responsible for five key services: supplementary nutrition, non-formal pre-school education, immunizations, health check-ups of pregnant and nursing mothers, growth monitoring of children under 5 years of age and referral to health facilities.
The ASHA and the Anganwadi are two of the most important essential elements of India’s public health system connecting communities to health systems and providing access to primary health services. They are the friendly neighborhood “superheroes” who want your child to eat better and grow into capable people who can contribute to the growth of their country. Evidence from studies of lancet has proven that the awareness work of ASHAs and Anganwadi workers at the community level has reduced neonatal mortality by more than 30%.
The ASHA and the Anganwadi are the friendly neighborhood “superheroes” who want your child to eat better and grow into capable people who can contribute to the growth of their country.
But unlike superheroes, responsibility and power don’t go hand in hand with our frontline heroes. While the swimming prodigy had a lot of power in his search for responsibility, ASHA and AWWs have more than enough responsibilities, but fight for power every day.
ASHA: The everyday struggle starts from day one
The problem starts at the root: it is women who take on these roles undertrained and are underqualified for the work they are asked to do. In the large federal states, basic orientation and training do not take place regularly; Those that lack the quality of knowledge transfer or equipping workers with the skills they need in everyday life. Furthermore, with government abhiyaans and missions piling up, the scope for refresher training in an already busy schedule is very limited. Ultimately, Frontline workers need to learn on the job, where reprimands, insults and sometimes even verbal abuse from superiors or beneficiaries are the reward for a job not well done.
ASHAs and AWWs are crucial to improving critical indicators such as maternal and child mortality, high-risk pregnancies, malnutrition and immunization, but they are also the most affected serious lack of quality equipment and infrastructure. Even light rain exposes leaky roofs Anganwadi centers where children come to receive education, vaccinations and nutrition. ASHA kits operate with malfunctioning thermometers, scales and hope, while anganwadi workers battle malnutrition with non-functional monitoring tools and a shortage of take-home meals and rations. However, when a critical event inevitably arises, frontline workers are the first to be targeted by block and district officials who threaten to cut their marginal salaries. In the worst-case scenario of mortality or lack of timely intervention, village workers face suspension and dismissal.
Looking for empowerment
It is true that while appointment to these roles makes them important stakeholders in the village, particularly on health issues, it still does very little to empower the role. Many who argue that the incompetence of frontline workers is due to an inherent lack of motivation and complacency cite examples of success stories and celebrate ASHAs and Anganwadis who have a strong voice in their village, as they should. However, they often overlook that the small proportion of these workers who actually have a stronghold come from families or sources that already enjoy a sense of empowerment in their region, which gives them access to relatively better education and knowledge compared to their colleagues.
ASHAs and AWWs perform much of the core public health work, which includes maintaining countless registries and surveys of key data points related to their work. While many see their role and work as empowering, the truth is that they do work that the men of the village consider too superior and the health authorities consider too inconsequential. And yet despite this lack of reward in terms of pay or promotion, quality equipment, training and, above all, dignity and respect, ASHAs and AWW save livesThey spend their money to accompany mothers and children in critical situations to hospitals, and walk through miles of villages to visit an at-risk newborn or check on a mother who hasn’t visited the anganwadi for weeks. All the while, they simultaneously take care of their homes, cook meals, clean, and manage expenses because, just like at work, they would be the first in the line of fire if something went wrong at home.
ASHA and Anganwadis: A United Front
Ultimately, community health workers rely on their own support during critical times. These workers have strong unions in every state and county that regularly fight for wage increases, protective equipment, better infrastructure and, most importantly, permanent employment. The recent 265 day strike The formation of the Kerala ASHA Workers Union is an example of the sense of community that exists among ASHAs across the country. But in many states such as Delhi, Haryana and Madhya Pradesh, workers are also being criminalized in their fight for justice. In many cases in Madhya Pradesh, ASHA employees have been laid off because of strikes, served notices for the demonstration of block managers or district officials, or police proceedings were initiated against them.
For India’s community health workers, adversity is not an exception but a defining feature of their professional lives. Lives shaped by structural constraints and ongoing challenges. The solution to their problems may not be a series of one-dimensional reforms, but may start with something as simple as dignity of work.
For India’s community health workers, adversity is not an exception but a defining feature of their professional lives. Lives shaped by structural constraints and ongoing challenges. The solution to their problems may not be a series of one-dimensional reforms, but may start with something as simple as dignity of work.
To improve the state of our public health service, we must take a critical look at the state of our frontline workers. Ultimately, the system is only as good as the final person responsible for managing it and being its ambassador. Currently it is powerless, unqualified and suffering from a crucial inadequacy. Therefore, the last mile of public healthcare would always be “women-led” rather than “women-led” until ASHAs and AWWs receive better wages, promotion structures, equipment and capacity building through rigorous training. Spiderman’s powers were possessed by Tony Stark, who supported him with his billion-dollar fortune; Maybe we can start by giving our superheroes some strength, dignity and goodwill for their truly life-saving work.
