Across India’s rural villages, some 1 million women, with on average an 8th to 10th grade education, work as Accredited Social Health Activists (ASHAs). They are the formally unsalaried frontlines of India’s health system and are typically paid on an incentive basis for tasks like checking-in on expectant mothers or making sure children receive vaccinations when they’re supposed to. Already under immense pressure to deliver basic services in their communities, the ASHAs have experienced high levels of stress as a result of additional work responsibilities during the COVID-19 pandemic. Nevertheless, they may be key to achieving the United Nations’ third Sustainable Development Goal (SDG) of ensuring healthy lives and promoting well-being for all at all ages.
But how is this possible? Can 1 million ‘volunteer’ health workers really improve the public health system in India? And can it be done at a cost the nation can afford?
The short answer is yes, it can be done, and the ASHAs themselves—not an army of new medical professionals or freshly built hospitals—are the ones to do it.
Improving the ASHAs’ ability to deliver care and expanding the types of support they provide—such as mental health services—can seem like a monumental and very expensive task, particularly in the midst of the pandemic. However, when we approach the world’s problems through a human flourishing lens, it allows us to see the ways in which seemingly disparate issues are actually connected by the human element. Enabling and empowering people by strengthening their innate character strengths can be at least a partial solution to many of the world’s most intractable problems. Inner character strengths may be the key to improving the impact of the ASHAs.
The Power Of Mental Health
While the ASHAs have historically been focused on ensuring that community members have access to basic medical care such as antenatal, natal and postnatal care, or for the treatment of physical disease and injury, it is apparent that in India—as in much of the world—huge gains in public health could be had through improving mental health and treating undiagnosed cases of depression and anxiety. High levels of untreated stress and depression can contribute to numerous knock-on ailments such as heart disease, hypertension, weight gain and a myriad of other problems. Initiation of basic community-level treatments for such mental illnesses, then, can help reduce rates of these other maladies, and improve public health overall by reducing the strain on doctors, nurses and hospitals.
Consequently, Sangath, one of India’s largest mental health research organizations is implementing two programs in the state of Madhya Pradesh in central India, targeted at helping ASHAs with the delivery of mental health services and effective delivery of their overall services. The first of these programs, ESSENCE, focuses on teaching ASHAs the fundamentals and techniques of an evidence-based brief psychological treatment for depression called the Healthy Activity Program (HAP), already implemented in other global settings. Rather than teaching therapy skills as they would in an academic setting, we tailor the introduction of HAP concepts to already existing cultural traditions and activities. The ASHAs in the ESSENCE program participate in either a six-day face-to-face training or a 6-8 week digital course over a Moodle-based app. Either way, the course is tailored to their unique social circumstances, education level and attempts to take into account the various obstacles and biases they may face in their work. The goal is to build the capacity of ASHAs to recognize mental illness, specifically depression, and either help those suffering from it directly or help them seek additional services.
The second program, supported by Templeton World Charity Foundation, focuses on the mental health and well being of the ASHAs themselves, and it is here that the greatest gains may be had. In their day-to-day life and work, the ASHAs often face burnout or mental health challenges, whether it is from the regular stress of their job, high workloads, cultural factors and working at the bottom of system hierarchies. They likewise face a myriad of endemic challenges because of their socioeconomic circumstances, gender biases and the lack of resources in many communities.
The pandemic has presented an extraordinary set of challenges for ASHAs. During the early waves, they lacked adequate protective gear and had additional expectations placed upon them by public health authorities, first to conduct COVID-19 screening within their communities and later to engage in door-to-door vaccination support and roll-out drives. These pandemic activities were not only extra labor, but were also high risk and put them in constant contact with community members who were experiencing fear and anxiety of their own. All of these factors, when taken together, can result in high levels of untreated and undiagnosed mental health problems among ASHAs.
For ASHAs confronting their own mental health challenges, it can become increasingly difficult to deliver effective care within their communities, particularly given their lack of formal salaries or supporting institutions. Even as they seek to help members of their community in need, ASHAs are constantly grappling with the toll of their own emotional labor. Our second program (called ‘AANAND’ in India, meaning ‘happiness’) focuses on building the ASHAs’ own inner strengths like resilience, perspective, judgment, social intelligence, and also stress reduction, using the evidence-based framework of Positive Psychology Interventions (PPI), which have shown promising results in improving burnout, including in workplace settings outside India. Rather than the focus being on improving the mental health of their communities, the ASHAs in this program work on improving their own mental health. This is done through a 5-day residential PPI-based coaching workshop focusing on leveraging their character strengths, and then regular contact with the coach via telephone calls. This program looks in particular for ways to leverage pre-existing cultural norms and spirituality to improve mental wellbeing and reinforce pure positive character strengths.
Taken together, these two programs are a two-pronged approach to improving public health in the vast rural communities across India. By learning about HAP depression care, the ASHAs are able to help previously untreated people and mitigate many of the worst consequences of mental illness across the population. And by developing their own inner character strengths, the ASHAs themselves become more effective at doing their jobs.
Mental Health, Human Flourishing and the SDGs
Even small but statistically significant reductions (achieved within the scope of programs) in severity of mental health symptoms among the population, coupled with improvements in the delivery of care as a result of improved mental health on the part of ASHAs, can mean an enormous positive impact when implemented across India’s more than 1 million ASHAs and the corresponding villages and communities they serve. By the same token, these interventions can potentially be tailored to local cultural and spiritual norms and redeployed across developing nations in Africa, Asia and Latin America. Achieving the SDGs will require investment by governments and private entities, of course, but it also requires a realistic approach to leveraging existing resources.
These sorts of interventions, which seek to strengthen the health care professionals already on the front lines in India, are an example of what is possible when we focus on helping humanity flourish. ASHAs with greater usage of their inner strengths are better ASHAs, and the communities they work in will be healthier communities as a result. While it won’t happen overnight, programs such as ours, at scale, can create concrete positive improvements in health across nations and put humanity one step closer to accomplishing the ambitious goals of the SDGs.
Dr. Ameya Bondre is the Senior Research Coordinator of the ESSENCE and SHARP projects at Sangath, Bhopal that focus on integrating depression care into rural primary health care systems, and digital mental health solutions for remote care of people living with schizophrenia, respectively. With more than 10 years of experience, he is the co-investigator for AANAND project focusing on improving mental wellbeing of frontline workers. He earned an MSc and was a Global Health Field Placement Fellow of Johns Hopkins School of Public Health, with prior medical training (MBBS) from Seth GS Medical College and KEM Hospital, Mumbai, India. He has prior honours from MIT Solve (2019) and TEDx (2018) amongst others in public health.
Mr. Deepak Tugnawat is the Director of Projects at Sangath, Bhopal. He is trained in social work, public health management and physiotherapy, he has been working in the public health sector in India, for more than 11 years with a focus on the management of stroke patients and children with neurodevelopmental disorders, digital training interventions in mental health, and implementation research. He has several peer-reviewed publications in high-impact public health journals. He is also the co-investigator for AANAND, Burke, SHARP and SARATHA projects. He has been granted the permanent distinction of “Associate Fellow” at Royal Commonwealth Society, UK.
Dr. Anant Bhan is Sangath’s Site-Principal Investigator, ESSENCE, EMPOWER Tata Trusts/LMSAI, SARATHA & SHARP, and Principal Investigator, DRISHTi, TransCare COVID-19, AANAND and Co-Investigator, TransCare MedEd (Sangath Lead), EMPOWER J&J. He earned a master’s (MHSc) in Bioethics from the University of Toronto in Canada and is a researcher in global health, health policy and bioethics. Bhan is one of the leading voices on issues related to medical ethics and social justice in India. He is also the immediate past president of the International Association of Bioethics (2017-19), serves as an Adjunct Professor in Yenepoya University, and is a member of several committees.
