India's one million Accredited Social Health Activists (ASHA) win the Global Health Leaders award at the 75th World Health Assembly: Time to move beyond rhetoric to action?

Accredited Social Health Activists (ASHAs) started trending on social media platforms since Dr. Tedros Adhanom Ghebreyesus, Director General of the WHO, announced six Global Health Leaders awards during the opening session of the 75th World Health Assembly (WHA) on the 22nd May, 2020.¹ While five of these prestigious awards have been given to individual leaders and a group, the informal unorganized Indian women cadre of ASHAs were recognized as the sixth awardee, for the crucial role they have played in “linking the community with the health system, to ensure those living in rural poverty can access primary health care services, as shown throughout the COVID-19 pandemic.”¹

The global health community is hailing ASHAs with pride and celebration for this rare recognition, the value of which we are keenly unpacking. While Indian citizens declared this as our historical moment, for the international fame ASHAs have brought, few of us are deliberating on what an award that goes to a million women who cannot be named on a global platform, has to offer to the ASHAs, who work in and belong to the said ‘communities living in rural poverty’.

The importance and impact of ASHA's^2,3 role is well researched. These million plus women health workers are being lauded for their pandemic-related responsibilities of surveillance, screening of returning migrants, awareness building, contact-tracing, aiding COVID-19 related surveys, facilitating access to services. They have put themselves and their families at a significant risk of exposure to COVID-19, stigma, violence, and social boycott from their community; with bare minimum to often no personal protective equipment (PPE) or assured support for priority treatment. Their other non-pandemic duties include (but not limited to) facilitating access for pregnant women for antenatal care, institutional births, postnatal care, immunization services, family planning services, surveillance and prevention of non-communicable diseases, nutrition, and care for chronic conditions. This largest cadre of women who ‘chose’ the profession of a voluntary worker receive only 20–60 dollars per month but work for 6–7 h a day which increased earlier to 10–12 h during the pandemic peak.

What ASHAs want

ASHAs have been utilizing diverse platforms4, 5, 6 to raise their challenges and issues in the last few years. Women in Global Health (WGH) India chapter, during dialogue with ASHA workers, their union representatives and policy leaders engaged with the ASHA programme, highlighted their issues in the pandemic. These challenges concerned their increased burden of work; inadequate training to undertake the new roles; denial of adequate safety from violence and infections; their rightful demands of recognition and respect from government as well as community; and most importantly the lack of appropriate and timely remuneration.⁷ Below is a list of recommendations based on this dialogue.

• •Develop institutional mechanisms for integrating ASHA's experiences, needs, and class, caste and gender realities in policymaking.
• •Develop and disseminate clear and concise guidelines for ASHAs.
• •Establish a capacity building strategy, in relation to use of technology and initiate supervision initiatives.
• •Develop support systems for grievance redressal as well as ensuring the physical and mental well-being.
• •Initiate broader health system reforms including strengthening policies for fair recruitment and remuneration, retention, financial protection, leave management, protection against sexual harassment, physical and mental health protection, and stigma prevention with clear accountability.

The revived opportunity for the global health community

While this recognition at a prestigious global platform is unique and rare, the issues faced by ASHAs, remain the same. These challenges are more complex when understood from the axes and intersection of class, caste, and gender-based disparities in India. Recognizing ASHAs as Global Health Leaders is a crucial step in the right direction, but it should be considered an opportunity for the global health community and policy makers to reflect on the relative power and agency of ASHAs in the hierarchical and power laden health systems in India. We believe this community has the power to move beyond the rhetoric of recognition and awards to work towards the action of mobilizing effective solutions and resources to support ASHAs.

It is timely to call out on the unjust, unfair, and even unethical practice of seeking voluntary services from a cadre that is brimming with power-based and gender-based issues in the Indian society and health systems, rather than celebrating their sacrifices. This award will be more valuable for ASHAs, if it makes them equal partners in health systems; mobilizing national support, domestic and external resources to create solutions to their long pending rightful needs and demands.

Contributors

SA & KM both conceptualised and wrote the manuscript.

Declaration of interests

SA and KM have leadership roles in Women in Global Health (WGH), India Chapter. Authors have no other conflicts of interests to declare and received no funding for this paper.