How about adolescent health workers?

Some would consider it a fresh start, a new opportunity to fulfil the national promise of “health for all”. Despite India’s mediocre performance in the health-related agenda of the Millennium Development Goals (MDGs), all may not be lost. Later this year, the unfinished MDG agenda will be addressed by a new set of milestones for global development, termed “sustainable development goals” (SDGs).

Indicators for these very specific and measurable goals — designed to finish the job of the MDGs over the next 15 years — were developed in July by 193 UN member states. Come September, and Prime Minister Narendra Modi will be uniting with other world leaders to sign the final document at the UN General Assembly.

Here’s the unglamorous part of the situation for India: the work required to meet basic health goals on issues such as maternal and infant health is colossal. Despite our “progress” on the economic front, we lag terribly in health indicators. Other neighbouring countries like Sri Lanka, Bangladesh and Nepal are far ahead. The stark failure of basic public health services is evident from the draft National Health Policy framed in January: Over 63 million Indians are threatened by the prospect of poverty caused by the massive costs of healthcare.

The SDGs, however, provide the opportunity to review this failure, and incorporate the lessons learned into a new agenda. Here are some of the SDG goals: “Reduce maternal mortality to less than 70 per 100,000 live births (we are at 178 now); end preventable deaths of newborns and under-five children; end the epidemics of HIV, TB, malaria and neglected tropical diseases; reduce by one-third premature mortality (deaths before age 70) from non-communicable diseases…provide universal health coverage…access to essential medicines and vaccines to all; access to sexual and reproductive health services.”

This is a long, long list. Strengthening the healthcare delivery system among poor and vulnerable Indians is central to achieving these targets. Innovative strategies are essential in rural areas where doctor shortage and disorganised urban primary health centres are the norm.

Community health workers (CHWs) play a particularly important role in linking communities to health services in such regions. These workers serve as an interface between the public health system and members of the community.

In the national programme, frontline female workers known as Accredited Social Health Activists (ASHAs), are regarded as the ‘first port-of-call’ for any health-related demands of the deprived sections of the population.

Each ASHA is expected to cater to the health needs of one village of 1000 people, and contribute to national disease control programmes — from leprosy to TB, malaria and cancer. ASHAs are supposed to educate everyone about these diseases, test blood samples, collect data, distribute medicines, as well as ensure that people access medical services.

Apart from this, the ASHA has to maintain her regular routine of counselling people on healthy practices; interacting with various village authorities on health and sanitation issues; educating communities about family planning, and escorting pregnant women to health centres for check-ups and deliveries; providing medical care for minor ailments, maintaining village and household level records as well as stocking essential items like ORS, condoms, iron and folic acid tablets, and so on.

Though the idea of ASHA was born during the National Rural Health Mission (NRHM) in 2005, this Florence Nightingale of rural India remains central to the current national health mission too. Guidelines on the selection and training of ASHAs are available on the NRHM website (they are paid incentives rather than salaries). To date, there are more than 8 lakh such workers in the country, one of the largest and fastest growing groups of rural working women in the country.

But this doesn’t mean much. Though the ASHA has great potential to create a synergy between the resources of the community and those of the government, this is not being realised. Despite her pivotal role in the public health system, her job is often thankless. On paper, she is supposed to receive support at the village level from women’s committees, the health and sanitation committee of the gram panchayat, and peripheral health workers. But the reality is that the ASHA has to fend for herself most of the time.

Financial incentives don’t compensate ASHAs for the logistical complexity of their jobs: they are expected to walk for miles and miles, from house to house, and accompany women in labour to hospital at odd hours, without transport or allowances. The ASHA’s monetary compensation is incentivised and performance-based, so delayed payments and a lack of clarity on “who is paying how much for which job”, as well as zero incentives for some work (such as patient referrals and data management) are deterrents.

Surveys show that many ASHAs don’t have the requisite knowledge or skills to perform their jobs, since they haven’t completed the stipulated month of training recommended by the ministry of health and family welfare. Regular supervision is missing, and refresher-training courses are inadequate.

Changing the dead-end situation of the ASHA calls for amplifying her opportunities — by increasing her incentives for every year of completion, or considering her for training as an ANM (auxiliary nurse midwife), after five years of successful performance. Redefining the role of the ASHA by dividing her responsibilities among other community members is another way forward. Both youth and men in villages are ideal candidates for the job.

Adolescents are effective agents of social change and India is home to 234 million, the highest number in the world. Scattered projects show that these young people can improve the health status of their communities if given the chance: schoolgirls in Ranchi are called “ doctornis ” after a local school made them educators in anaemia. They talk to their friends and families about healthy nutrition and the importance of consuming zinc, folic acid and vitamin C.

In Muzaffarpur district of Bihar, adolescents have proven themselves to be effective educators on HIV and AIDS. Both examples show how the power of adolescents can be tapped to tackle the unfinished health agenda of the MDGs. In the search for solutions, we often overlook the obvious ones.

The writer is a microbiologist who specialises in writing about health issues