Heralding a health revolution: female Community Health Workers in rural Rajasthan
Author: State ASHA Resource Centre and State health system resource centre
Rajasthan is India’s second largest state and has a poor record for several health and human development indicators. Morbidity due to communicable diseases is high; the infant mortality rate in the state is 63, against the average of 53 at the national level; the maternal mortality rate is 388 against the national average of 254, and the birth rate is 27.5/1000, compared to the national average of 22.8/1000. This underscores the need to involve the community more effectively in this state to expedite health improvements.
The National Rural Health Mission of the Government of India has specifically sought to increase the level of “communitization”, as a necessary complement to the country’s health systems edifice. A critical aspect of this was the appointment of community-based female health workers known as Accredited Social Health Activists (ASHAs). ASHAs typically have secondary schooling-level education, are between 25 and 45 years of age, and belong to the local communities. They provide a wider range of services including information, counseling, community mobilization and escorting women to health centres for pre-natal and ante-natal services. In addition to this, the Ministry of Women and Child Development run “Aanganwadi” centres, where care services are provided for young children. In Rajasthan, the state government recruited additional women health workers, known as “Sahyoginis” to assist the Ministry of Health’s ASHA workers, as well as the Aanganwadi workers.
Sahyoginis were oriented to the role of ASHA to avoid duplicating the field work done by the Ministry of Health. Eventually, in Rajasthan, these volunteers were designated as ASHA-Sahyogini workers. They work on providing information, as well as assisting the delivery of a number of health-related services including for pregnancy and childbirth, infertility, adolescent health, immunization, nutrition, hygiene and sanitation.
Training of ASHA Sahyoginis is a critical component for their effective functioning, and is a continuous process. An initial training of about 23 days is provided over 4 rounds. 7 modules of training have been developed for this purpose. These include:
- Overview of health and medical care
- Maternal and Child Health
- Family Planning, RTI/STIs, HIV/AIDS and Adolescent Reproductive and Sexual Health
- National Health Program, AYUSH (traditional medicine) and management of minor ailments
- Personal development
- Skills that save life in Maternal and Newborn Health
- Skills that save life in Child Health and Nutrition
To provide further support to the health workers, the Government of Rajasthan has set up a State ASHA Resource Center and State ASHA Mentoring Group. The former provides technical support and inputs, while the latter acts as a think-tank for the programme.
43,789 ASHAs have been appointed in the last three years. Out these 40,361 have been oriented using the first two training modules; 33,811 have been oriented on the third module; and 32,652 on the fourth module. While training is yet to be conducted for most ASHAs for the other modules, the existing ASHAs, along with sahyoginis, are playing a critical role in providing essential information and services across rural Rajasthan. They serve as a bridge between people and health facilities to ensure that the goals of National Rural Health Mission are met.
The ‘communitization’ of health services may require the recruitment of community workers at multiple levels and in various capacities. As multiple ministries/ departments may be involved in the delivery of health services at the community level, care must be taken to ensure that there is no duplication of efforts. The case of appointing health worker assistants/ sahyoginis in Rajasthan provides an interesting example of doing this, as these workers are appointed to support community outreach for the activities of the Ministries of Health, and Women and Child Development.