Digital ID in the time of COVID-19 in India

Posted on by MSC

India’s social welfare delivery system relies on Aadhaar, a biometric digital ID system, to identify and authenticate beneficiaries. About 800 million people use biometric authentication to receive highly subsidized rations every month through the Public Distribution System (PDS). Similarly, millions of beneficiaries use biometric authentication to withdraw money that they receive from social welfare programs and other sources through bank agents, known as business correspondents (BCs). Almost all these transactions rely on a single technology, that is, fingerprint-based authentication. 

On 25th March, 2020, the Government of India (GoI) announced an unprecedented nationwide lockdown to curtail the spread of COVID-19. To mitigate the lockdown’s social and economic impact, the GoI rolled out several measures related to welfare and relief. The Pradhan Mantri Garib Kalyan Yojana (PMGKY) was the first such measure and included free food grains and cash aid for the poor and vulnerable segments.

During the lockdown period, and even now, fingerprint-based technology was the primary mode for beneficiaries to authenticate themselves to access benefits under the PMGKY and other social benefit transfer programs. The high-contact nature of fingerprint technology created apprehension among service delivery agents and beneficiaries due to the risk of COVID-19 transmission. In the absence of any reliable alternate technology, they had no other option but to use their fingerprint. 

Alternative modes of authentication have been required for a long time, primarily to reduce failure and manage exceptions. For example, studies show that out of the ~7 million Aadhaar-enabled payment system (AePS) transactions between December 2014-2018 facilitated by Business Correspondents (BCs), 34% failed –  of which 17% were due to biometric mismatch. During April, 2020, while  the lockdown was in effect and vulnerable populations tried to access their cash benefits, cash withdrawal transactions through the Aadhaar-enabled payment system (AePS) were as high as 403 million, which was almost double the transactions in the previous months. 

In line with this increase, the rate at which transactions failed in AePS was 39%. The main reason for such failures was a mismatch in biometric data. With limited to no exception handling procedures in place, this high rate of failure translated to millions of distressed and disadvantaged citizens who failed to withdraw cash. Instances of fingerprint authentication failure in the PDS, the most extensive government program to use Aadhaar, have also been reported for a long time. 

In this context, this blog examines the constraints that arise from the deployment of just one contact-based biometric authentication technology to avail government benefits. It also identifies contactless technologies to mitigate some of the challenges associated with fingerprint authentication.

The adoption of contactless biometric technology

Iris and facial recognition are two viable alternatives to fingerprint authentication that offer the highest level of security, that is, validation of who you are, which characterizes India’s biometric authentication process. The table below benchmarks, these authentication technologies across various observable parameters:

Fingerprint matching technology is accurate and has proven to be highly scalable. However, it struggles to read damaged prints and requires users to physically place their fingers on a surface, a risky proposition during a global pandemic.

Iris recognition has the advantage of high-speed authentication, is highly accurate and mature, and relies on scanning the iris, which is less prone to degradation over time than one’s fingerprints, as with the case of the elderly or those engaged in heavy manual labor. However, successful usage depends on user training as the devices require specific positioning of the iris. Success also depends on robust internet connectivity, as the data packet transmitted to the Aadhaar central repository for authentication is much larger than that of the fingerprint-based system. 

Another feasible contactless technology is facial recognition technology (FRT), which relies on consistent facial features despite aging or surgery or both. This biometric technology is affordable and widely available as part of multifunctional devices and across form factors, making it cost-effective and potentially scalable. Globally, law enforcement agencies dominate the use-cases for FRT. Yet more recently, India has utilized FRT for digital ID authentication. 

In the past, the country was conservative in its adoption of FRT for ID authentication owing to concerns around privacy and existing investments in fingerprint and iris scanners. However, the tide seems to be turning, in part due to studies that have shown the effectiveness of facial identification. In August 2018, the Unique Identification Authority of India (UIDAI) formally included FRT as an option for Aadhaar authentication. Sector experts have been deliberating about the potential to identify and track COVID-19-positive Indian citizens using Aadhaar-integrated cameras equipped with thermal scanners. UIDAI currently holds images and contact details for approximately 1.23 billion people which can be leveraged after assessing the quality of images captured. 

FRT case study: Bangladesh

In October 2019, Bangladesh conducted its first Electronic Know Your Customer (eKYC) pilot. Rather than relying solely on the current practice of four-finger biometric authentication, the government opted to try its home-grown FRT created by Giga Tech Ltd. Of the total 19 banks participating in the pilot, approximately half were assigned fingerprint authentication technology, while the remainder received FRT. Bank employees and agents confirmed the relative ease of using camera phones or tablets to capture beneficiaries’ photos and complete the e-KYC process. Although fingerprint authentication was more readily adopted due to familiarity with the technology, FRT was found to be an efficient contactless technology on par with fingerprint technology. Despite the pilot’s short-term nature, MSC’s analysis suggests that standardizing the biometric devices in terms of hardware and software specifications, issuing detailed FRT instructions, and delivering training sessions would make FRT a leading contender in e-KYC systems. 

Let us consider equipping the PDS with alternate technologies—iris or FRT—in addition to the existing fingerprint-based ePoS. Equipping all the fair price shops (FPS) in India with an iris scanner that can be integrated with the existing ePoS will cost USD 60-163 million. For FRT, this cost will be around USD 54 million if a phone or device is also provided to all FPSs. However, the cost would be negligible if the dealers already possess a smartphone and only an agnostic software application needs to be developed. 

Adopting other exception management protocols 

Besides adopting a nascent technology such as FRT, it is also possible to work within the confines of existing authentication infrastructure to ensure the safety of India’s citizens while limiting exclusions. Such approaches entail the active use of exception management protocols, such as one-time passwords (OTP). This is already part of the protocol for PDS. During the lockdown, PDS dealers in Rajasthan and Karnataka conducted exception handling through OTPs. 

As per the Indian Telecom Services Performance Indicator Report as of June 2020, India’s average teledensity was 85.85%, with urban and rural teledensity at 137.35% and 58.96%, respectively. Such widespread mobile penetration makes OTP-based ID authentication feasible, safe, and cost-effective. Moreover, citizens with an Aadhaar card are encouraged to register their mobile numbers to avail different services. Therefore, mobile numbers are already linked to Aadhaar cards, and no additional effort or data collection is required to use this exception management mechanism. 

Requesting and using an OTP ensures a satisfactory level of contactless identity authentication and reduces exclusions due to worn fingerprints or interrupted service, resulting in a smooth flow of benefits. However, the challenge in this method is that the most vulnerable populations still might not have access to a phone or may change their numbers frequently. 

Conclusion

The COVID-19 pandemic has seen the beneficiaries of the government’s welfare programs either being increasingly excluded or inconvenienced due to the reliance on a single mode of authentication. Biometric-based ID solutions were rolled out, in part, to address such exclusions. However, the contact-based nature of fingerprint technology potentially creates additional health risks for millions of vulnerable people. 

The solution may not lie in phasing out or eliminating fingerprint authentication but in providing      safer, contactless, and alternative verification options using different technologies. This would ultimately avoid exclusions and ideally eliminate them. Currently, exception handling technologies are sparse, and their usage sporadic. For example, in PDS delivery, only eight states have reported Aadhaar authentication using iris scanners. In the case of banking services, alternate technologies are limited to small-scale pilots. 

The newer technologies we covered in this blog have the potential to coexist as robust alternative methods of identity verification to not only assure beneficiary safety but ensure the delivery of benefits. Deploying alternative technologies should be done after considering factors like areas with higher rates of failure, network and server issues, and last-mile service providers’ ability to afford and operate the devices. The government can adopt a phased approach to test the technology after running pilots to ensure that the transition is smooth and sustainable. It has become critical to strike a balance between identifying the recipient accurately, preventing pilferage and delivering government benefits without interruptions. Innovation in the area of authentication technology will be a meaningful step toward achieving this symbiosis.

A Silver Lining During the Pandemic: Three Financial Inclusion Success Stories in the Age of COVID-19

Posted on by MSC

This blog talks about the Financial Inclusion Lab accelerator program, which is supported by some of the largest philanthropic organizations across the world – Bill & Melinda Gates Foundation, J.P. Morgan, Michael & Susan Dell Foundation, MetLife Foundation and Omidyar Network.

COVID-19 has given us all so many hardships over the past few months, while dramatically impacting businesses across practically all sectors. When it comes to financial inclusion specifically, the pandemic has sparked widespread talk about a widening digital divide, rising inequality in gender inclusivity, growing skepticism over informal financial practices, and concerns about overlooking financially vulnerable customer segments.

However, the crisis has also generated ongoing inspirational stories about a few Davids who are fighting and winning their battles against these Goliath-sized problems, one blow at a time.

In this article, we hope to draw your attention to three of these success stories.

Boosting gender inclusion

Data, digitalization and business acumen, if used the right way, can lead to incredible results for gender inclusion.

One such case involves one of MSC’s Financial Inclusion Lab startups, Frontier Markets, which has done commendable work to address the pandemic’s impact on vulnerable women.

Frontier Markets empowers rural women to become entrepreneurs. It is building a last-mile distribution network through these women entrepreneurs, whom it calls “Saral Jeevan Sahelis” or “Easy Life Friends” (in Hindi, saheli means a woman friend). Through this network, it delivers world class products/solutions, such as Samsung refrigerators and Philips solar lighting systems, to the remotest households in rural India.

Until a few months ago, most of Frontier Markets’ data was non-digital and scattered across different teams. As a result, these teams were not able to leverage this data to generate holistic benefits for the broader organization.

To address this issue, the Lab and the Frontier Markets teams came together to build an impactful data strategy to increase the productivity of Sahelis, and the results proved to be impressive. We worked together to digitalize and assimilate the disparate data points, cleaning up the data and drawing some useful data models for enhancing the productivity and earnings of the Sahelis, using various machine learning techniques – the usual data science stuff. Leveraging the power of these techniques, we helped the Frontier Markets team build a strong product recommendation engine that mapped each Saheli’s expertise in selling a particular product to the hyperlocal market need for it in her area.

So, what’s so impactful about this, you ask?

Through these data-based product recommendation models, both the number of customers as well as the number of products sold on the platform saw a 4.5x increase in a short period of time. This created a huge impact on the livelihoods of the Sahelis:

  • Average business per Saheli increased by 150%
  • The number of women recruited and trained to become Sahelis grew by more than 3x
  • Sahelis’ income per sale grew by 20-30%

There were also other, more intangible benefits. For instance, more Sahelis talk proudly now about how their social status within their communities has changed positively, and how they have become an inspiration for many other local women.

Changing the trust perception about chit fund companies

Despite their global popularity and widespread benefits to communities that lack formal financial access, rotating savings and credit associations or “chit funds” are sometimes perceived as a dubious activity, because their model may seem to resemble “Ponzi scheme” scams. However, chit funds are actually one of the most effective informal financial tools. They enable the low and moderate income (LMI) segment to save and borrow through friends, family and other community members, who pool their money together into a common fund, from which each group member can withdraw money in turn.

As seen through the example of Chitmonks, a blockchain-powered chit fund digitalization company described in one of MSC’s 2020 publications, the chit fund sector also has immense potential to boost the formal financial inclusion of chit fund group members – especially if the transaction data of their groups is digitalized. But the biggest roadblock towards building trust in the eyes of both potential chit fund subscribers and financial institutions is their lack of proper auditing. Even for the chit fund companies that are registered with the government, it is very hard for the government regulator to audit the manual record of transactions, which are saved in multiple stacks of papers on a regular basis. It would be akin to auditing the transactions of multiple people belonging to multiple groups (8-10 people per group) across weekly, fortnightly or monthly interactions over decades of time.

To address this concern, the Lab is supporting Chitmonks by building a robust data strategy plan and implementation roadmap that will enable it to:

  • Design data analytics models to identify any possible compliance violations by the chit fund companies it works with (which may include a failure to promptly account for group member transactions, a failure to renew the company’s license, etc.) so they have a chance to rectify the mistakes.
  • Prepare models to evaluate and rate the various chit fund companies that use its platform, based on their compliance records on the blockchain.
  • Create a digital history of chit fund subscribers. This will enable them to obtain loans and other financial services from formal financial institutions at lower interest rates than they would otherwise get.

Through these features, a whole host of issues plaguing the chit fund industry (such as the ones described in our blog on Chitmonks) will be solved.

Inclusive digital marketing for LMI customers

Financial service providers in emerging markets want to reach LMI customers more effectively, and digital marketing offers a popular solution. But one of the biggest problems these providers face in reaching these customers has been their inability to properly leverage digital media. Traditionally, physical marketing has worked best to reach out to this segment. This is because physical marketing is based on word-of-mouth trust building and, in many cases, handholding the customers and training them in how to use the financial solutions the providers are offering.

However, the pandemic has forced a massive change. With lockdowns and restricted mobility, it quickly became impossible to physically reach out to local businesses with product offers – especially those run by LMI entrepreneurs, such as mom-and-pop stores. These limitations rendered many sales teams virtually jobless, as a bulk of their daily activities had consisted of meeting, chatting with and prospecting new customers, then walking them through the processes involved in using their financial solutions.

In response to this challenge, adaptive, agile financial service providers – especially fintech startups like Bridge2Capital – have realized the importance of leveraging digital media to market their solutions to LMI businesses. But they’ve faced the basic question of how to design effective digital marketing campaigns for these customers.

Reaching out to the LMI segment is not a simple copy-paste approach, in which financial service providers can borrow digital marketing ideas used for other, higher-income, more tech-savvy customers. It requires new tactics designed for LMI customers’ unique needs. To support Bridge2Capital’s efforts on that front, the Lab stepped in to help it:

  • Understand the most effective ways of reaching out to this segment in terms of language (vernacular or mixed) and social media channel preference (YouTube, Facebook or WhatsApp messaging).
  • Design core strategies for reaching out to the LMI segment and building brand appeal among these customers.
  • Build an implementation roadmap to engage, sell to and provide empathetic customer care for LMI customers, by closely emulating the in-person sales and marketing behavior that they are traditionally used to.

Although the complete picture with regards to the results of these digital strategies is yet to be seen, the initial indications look promising. Bridge2Capital’s engagement with the LMI segment is growing, and this has much to do with these customers’ changing attitudes and growing affinity towards digitalization since the start of COVID-19. However, even with this new openness to digital approaches, human-centric digitalization remains key.

While COVID-19 has had a disastrous impact on the world’s health, finances and social interactions, it’s good to recognize the silver lining exemplified by the businesses above. If we can take these positive examples and build upon them, even after the pandemic has ended, then the dream of financial inclusion can still be achieved.

The blog was also published on Next Billion on 25th of January, 2021

 

 

 

Preparing for life after COVID-19: How India’s healthcare system can better respond to future shocks

Posted on by MSC

India’s public healthcare system was tested by the onset of COVID-19. Now that a vaccine promises to bring the end phase of the pandemic (gradually) into sight, it’s time to take steps to make the system more robust and dynamic to better absorb such shocks in the future, so the country can reliably deliver healthcare to its 1.3 billion people – particularly the two-thirds who live in rural areas.

To investigate how the public health system and its beneficiaries have fared in the pandemic, MicroSave (MSC) studied low-income households in the states of Uttar Pradesh, Odisha and Bihar. These states have among the worst healthcare indicators in the country. Almost all the households we surveyed fall below the government’s poverty line, and their average monthly income was around Rs 9,800 ($130). We also surveyed community healthcare workers, called Accredited Social Health Activists or “ASHAs,” who act as an interface between the community and public health services. The study was conducted over the phone, between late June and mid-July of last year.

Here are our findings and recommendations for better future preparedness.

ISSUE 1: DISRUPTION OF ROUTINE HEALTHCARE SERVICES

One outsized impact of the pandemic was that routine primary healthcare and basic family planning services were not available for some time. On March 24, India was placed under a nationwide lockdown to curb the spread of the novel coronavirus.

Following this, local healthcare centers were either shut, or were lacking medical staff. Many hospitals and medical workers were dedicated to treating patients with COVID-19. In our study, 71% of ASHA workers said that existing resources like doctors, nurses and other paramedical staff, ambulances for referral transport, etc. had been reallocated to healthcare centers treating the virus.

The result: Pregnant women could not get their check-ups done, some were turned away when they went to healthcare centers to deliver their babies, and children could not get their vaccine shots. Around two-thirds of ASHAs said that antenatal care was not provided in their communities in April and May, and 38% reported that routine immunization services were also affected.

This disruption was a blow to India’s health mission, which places great emphasis on reproductive, maternal, newborn and child healthcare. Many of these services are time-bound: A child who misses one dose of her immunization schedule can’t make up for it later beyond a certain period. These breaks in the cycle could lead to increased morbidity and mortality among mothers and children later on.

Outreach services, like Village Health, Sanitation and Nutrition Day, were also interrupted. These events are important in creating constant messaging about preventive medicine and other healthcare services and facilities – otherwise, people in rural India quickly forget. The pandemic interrupted this essential outreach.

Also, screening tests for communicable and non-communicable diseases like tuberculosis, HIV, diabetes and hypertension were halted, according to 65% of ASHAs. And finally, family planning services were disrupted. Across the three states in our study, ASHAs said family planning commodities for community distribution were out of stock. A third of the ASHAs said that there was demand for female sterilization, but no provision – a situation that would lead to unintended pregnancies. Family planning is an essential service in rural India, and should not be disrupted.

Recommendation: To prevent these issues in the future, policymakers need to allocate more resources – and redeploy existing resources – to healthcare. India currently spends less than 2% of its gross domestic product on healthcare, among the lowest in the world.

Additionally, in a future pandemic, some hospitals can be dedicated to pandemic care, but others should be left alone to carry out routine services. Similarly, instead of deploying all medical staff to pandemic duties, a portion should remain available for other healthcare needs. Hiring contract staff for a limited period could help.

Finally, the ASHAs we surveyed reiterated some long-standing demands: There should be at least one female doctor at each primary healthcare center, and infrastructure at government hospitals should be improved. These hospitals do not have enough beds and they are crowded at peak hours, according to the ASHAs. There should also be emergency services such as ambulances available, particularly at night.

ISSUE 2: BARRIERS TO HEALTHCARE ACCESS

In the early months of the pandemic, individuals found it difficult to access healthcare due to three main reasons.

The first reason was the challenge of transport: Public transport services, such as buses and auto rickshaws, had come to a halt in the early stages of the crisis. In our study, 44% of households said they were dependent on public transport to go to their nearest hospital. One male respondent in Odisha was at wits’ end regarding a check-up for his eight months-pregnant wife. “I cannot carry my wife on the bicycle to the primary healthcare center. What should I do?” he said. Meanwhile, many people feared to use ambulances, because those were also being used to transport patients with COVID-19.

The second reason involved financial challenges: Many people lost their jobs and incomes due to the lockdown. They cut down on all expenditures, including non-urgent healthcare. In our study, 14% of the people who fell ill during the pandemic with common ailments, like gastric issues or joint pain, said they didn’t seek medical help because of the costs involved. Around 31% said they cut back on food and clothing to pay for healthcare costs, while still others said they took loans from friends and relatives, or sold their agricultural produce at steeply discounted prices. And three-fourths of respondents said they did not have any health insurance.

Meanwhile, out-of-pocket expenses on healthcare went up. People now had to buy masks. The lack of public transport, and the lack of resources at government hospitals (along with these facilities’ poor quality of service) pushed people to more expensive private clinics. For instance, some respondents to our survey went to a private hospital due to the lack of X-ray and ultrasound test facilities at their primary health center. Among the respondents who fell ill during the lockdown, 59% said they went to private providers. They found that some doctors had increased their fees by 5%-10%, while the cost of medicines rose by 10-15%.

One ASHA worker from Bihar said that when she took a tuberculosis patient to the primary health center, the staff was busy with COVID-19 patients, and asked them to visit the next day. The following day, she said they took a sample and referred the patient to a district hospital in another town. “The patient got irritated and went to a private lab,” she said.

The third reason involved social stigma: Many respondents delayed going to the hospital for any ailment, because of the social stigma attached to it — neighbors might think they had COVID-19. “If I get COVID-19, people will look at me as if I have made a blunder and failed to protect my family,” said one male respondent from Odisha.

In our poll, 42% blamed the pandemic for restricting their access to healthcare. And around 71% of our respondents believed that hospitals were hotspots for contracting infections. A small fraction — 12% — even believed that hospitals were only treating COVID-19 patients.

Recommendation: Each of these obstacles to healthcare access can be addressed by targeted interventions.

First, more households should be brought under the government’s insurance programs, to reduce the burden of out-of-pocket healthcare costs.

Second, the availability of transport like ambulances should be streamlined, to compensate for the interruption of public transport system during pandemics.

Third, communication should be stepped up. In addition to the government’s existing efforts on Information Education Communication and Behavior Change Communication, policymakers can introduce Social Behavior Communication interventions to alleviate people’s fear of COVID-19 (and future viruses) and their associated social stigma.

In rural areas, people easily forget about the need for prevention and immunization, so it’s essential to keep pushing that message. This will be especially important in the coming year, to make people open to vaccination against COVID-19.

ISSUE 3: CHALLENGES FOR FRONTLINE HEALTH WORKERS

ASHAs have been on the frontline of India’s fight against the pandemic, but their work, especially in the early days, has been fraught with challenges.

On the one hand, they could not fulfill their basic tasks, like escorting pregnant women to the nearest primary healthcare centers. On the other hand, they were asked to pitch in with COVID-19 related tasks, like conducting household surveys to seek out infected people – but without training and safety equipment.

Recommendation: We propose several policy changes to strengthen the standing of ASHAs, starting with providing them a minimum income, health insurance and equal treatment with formal employees of the government healthcare system. (ASHAs are not government employees, and have traditionally been paid incentives for facilitating healthcare service uptake.)

In addition to resolving the specific challenges mentioned above, the government can use technology, and specifically telemedicine, to take care of people’s basic healthcare needs. Most of our survey respondents felt positively about the idea of getting a medical consultation over the phone, though some were skeptical about how they would know if the person on the other end was a doctor. Telemedicine was more acceptable to those who live farther away from their primary healthcare center, and those who were dissatisfied with the existing government healthcare system. But though digital tools like telemedicine can be a solution for issues that surface during a pandemic lockdown or for similar emergencies, they are not an alternative to routine healthcare services. Since there are many challenges to this approach, involving digital literacy, smartphone access, internet penetration, connectivity challenges, etc., we propose it as an addition – not a replacement – to existing services.

The COVID-19 pandemic has taught India many hard lessons about the gaps in its current healthcare system. But in the process, it has highlighted some promising potential solutions, while focusing the attention of policymakers and other players on the need to plan for future pandemics and other emergencies. If this focus can be sustained after the current crisis has ended, the country’s healthcare system will be better prepared for the next one – which might already be lurking, even as we continue to cope with the current one.

This blog was also published on Nextbillion on 01 February 2021

 

Policy shifts to bolster India’s frontline healthcare workers

Posted on by MSC

The COVID-19 pandemic has put the spotlight on India’s frontline healthcare workers and highlighted the need to provide them with infrastructural support and resources to ultimately strengthen the country’s healthcare system. Accredited Social Health Activists or “ASHAs” are one such critical link in India’s efforts to ensure last-mile delivery of healthcare services. ASHAs are informal frontline healthcare workers at the grass-root level, who ensure effective and efficient implementation of government healthcare programs. They have acted as foot soldiers in the country’s battle to contain the spread of COVID-19.

However, ASHAs have long faced multiple challenges in executing their essential tasks, and these were exacerbated during the pandemic, according to our research. Still, they remained committed to their cause. “Working during the lockdown has been tough but irrespective of the situation, I always stand with people during their emergencies,” said one ASHA worker from the eastern Indian state of Odisha.

India has nearly 1 million ASHAs spread across almost all states and union territories. The country’s National Health Mission envisages having at least one trained ASHA in every village. Her role is to increase the utilization of public health services, such as by helping organize immunization drives, community mobilization, and escorting pregnant women to government healthcare centers for free checkups and deliveries.
When the pandemic struck, ASHAs had to balance their usual tasks with new responsibilities related to the pandemic.

To understand the impact of COVID-19 on the ASHAs and routine healthcare government services, we surveyed ASHA workers and beneficiaries in the rural areas of three states that lag in public health indicators—Uttar Pradesh, Odisha, and Bihar. The survey was conducted over the phone, between June and July, and respondents shared their experiences since the start of the pandemic earlier in the year.

The struggle to provide basic healthcare to communities

In the early months of the pandemic, many services related to reproductive, maternal, neonatal, and child healthcare—a key focus area of India’s healthcare program—were disrupted. The trigger for these disruptions was a nationwide lockdown that came into effect in late March to curb the spread of the novel coronavirus. In some instances, public healthcare centers were shut. ASHAs we spoke to reported that doctors and other medical staff could not reach these centers due to restrictions on transport and movement. “A pregnant woman came to me many times to get her ultrasound done but I could not help her as nothing was open,” said one ASHA worker from Bihar.

Many public healthcare centers were repurposed as COVID-19 facilities. In our survey, 71% of ASHA workers said that existing resources had been reallocated for COVID-19, and 66% said that this reallocation hurt routine healthcare services. Meanwhile, people were also wary of going to the health centers as they were afraid of contracting COVID-19.

The lack of transportation was another obstacle to accessing public healthcare. Typically, ASHAs use government ambulances to ferry expecting mothers. Yet ambulances were difficult to find as many had been diverted to be used for COVID-19 patients. Privately-run transport services were few and costly and thus posed as a barrier to healthcare access. In Uttar Pradesh, one ASHA said she was denied an ambulance for a pregnant woman, so the delivery was done at home. “I took care of the mother for nine months but in the end, it was all in vain,” she rued. Neither could the ASHA facilitate an institutional delivery nor did she earn any incentive for it.

In our poll, 63% of ASHAs said that antenatal care was not provided in April and May, though it resumed in June. Around half the ASHAs reported a decrease in “home-based newborn care” because families feared getting infected. A third of ASHA workers surveyed said that routine immunization services were affected, and a third also said that family planning services like sterilization were not available to women who wanted it. Disruptions in service not only inconvenienced the public but also hurt ASHA workers economically.

ASHAs do not get a salary and are instead paid incentives to perform certain services. For instance, they may get INR 100 in rural areas to bring an expecting mother to the local healthcare center for a checkup as part of antenatal care. Or, she may be given INR 300 to facilitate delivery in the hospital rather than at home. With services disrupted, incentive payments fell. Around half of the ASHAs reported a decrease in incentives tied to antenatal care, while 56% said that incentives for immunization reduced. Before the pandemic, ASHAs historically earned an average of INR 2,000 to INR 6,000 (USD 27 to USD 80 ) a month, depending on the state. “That is not enough,” said one ASHA worker from Odisha.

Moreover, ASHA workers faced delays in getting payments and when the money did come, they often did not know what they were being paid for. The inability to track the claims submitted by ASHAs has been a persistent challenge for them.

Foot soldiers in the battle against COVID-19

Even as their routine tasks suffered, ASHA workers were roped into the government’s efforts to stave off COVID-19. They were asked to build awareness of the disease and guide people on ways to protect themselves. Half of the ASHA workers polled were asked to track people suspected to have the infection and facilitate their visit to the hospitals.

However, 40% of ASHAs said they did not get training for this work. They were promised INR 1,000 (USD 14) to conduct household surveys to trace people suspected to have COVID-19. All three states also conducted surveys for “vulnerability mapping” to identify households with the elderly and other high-risk individuals, such as those with comorbidities. ASHAs were promised INR 1,600 (USD 22) for this survey.
However, at the time of our survey, nearly 40% of ASHAs said they had not received these payments.

Recommendations for a better future for ASHAs

The pandemic has reiterated the importance of ASHAs in India’s healthcare delivery systems. It has also highlighted the urgency of resolving the longstanding challenges they face through policy and structural changes. Here are our recommendations to help them overcome these hurdles:

1. Financial safety net: Provide ASHA workers basic financial safety through a minimum wage and health insurance. Almost all ASHAs we surveyed cited the absence of a fixed salary as a concern and cause for financial stress. They said they were on duty 24/7 but were not eligible for any benefits like insurance or vacation days. Some of them reported receiving fewer incentives than daily wage workers. “We are called ASHA [which means “hope” in Hindi] and we also have an “asha” of getting regular salaries,” quipped one worker from Bihar.

2. Payment reconciliation: Improve the system of payments to ASHAs by making the process easy to follow by increasing accountability and by reducing delays. Delayed payments and lack of transparency have long been issues for ASHA workers and were aggravated in the pandemic.
Typically, ASHA workers raise an invoice for services rendered. But instead of paying these invoices within a specified period, the government has been paying them erratically, in lump sums for several months. Some ASHAs said that although they had received an amount of between INR 2,000 and INR 4,000 during the lockdown—they were not clear what it was for. “We have no way to reconcile and know what services I have received this money for. The money we get never matches with our calculation of claims,” said one ASHA worker from Bihar.

3. Recognition: Consider providing ASHA workers better facilities on par with other public health staff. This is based on the concern raised by ASHAs that they get subpar treatment compared to other staff at public healthcare centers. For example, an auxiliary nurse & midwife, who is a government employee, usually has a designated space for herself at the healthcare center. In contrast, an ASHA worker who accompanies a pregnant woman for her checkup has to wait in the center’s corridors, like any other patient. Policymakers may consider including space for ASHA workers to sit at the healthcare center, priority in getting transportation to escort patients, and public recognition as a key member of the healthcare system.

4. Capacity-building: Develop competency frameworks to identify and fulfill the training needs of ASHA workers to enable them to meet their responsibilities. ASHA workers said that more training around screening for communicable diseases like COVID-19 would have prepared them better for their role in the pandemic. Policymakers should consider exploring digitally-enabled methods of training.

5. Support and resource: Provide resources and safety equipment to safeguard ASHAs before they can safeguard communities. Lack of protective gear during the pandemic was a common issue cited by ASHA workers in our interviews.

 

Footnote

[1] 1USD=73.98 INR as of 22nd December, 2020