Ground Reports

The Silent Plight of the Foot Soldiers of India’s Public Health System

“My wife Noormah Naaz was an active ASHA (Accredited Social Health Activists) worker in New Mustafabad. On April 24th this year she lost her battle to COVID-19 as she couldn’t get oxygen supply at the time of critical need. It is unfortunate that she wholeheartedly dedicated her services of the government during COVID but she was in dire need neither did her dispensary come for help nor did anyone else and she succumbed to the infection,” writes Mohammad Razekin in his letter addressed to Prime Minister Narendra Modi and Chief Minister of National Capital Territory Arvind Kejriwal.

By Rohin Kumar, 29 Sep 2021

“Sir, I want you to know that I am a factory worker who barely earns 8000 rupees a month and which is not even equivalent to the minimum wage decided by the government. I have three school going children. I am struggling to meet their education, health and food costs. I appeal to you to help me and my family as you are our elected representative,” Razekin further pleads and demands an immediate grant of compensation of 1 crore for his family.

The Dilli ASHA Kamgar Union (DAKU) supports the demand of Noormah’s husband. DAKU reminds the government: “It is a well-known fact that scheme workers continue to be seen as volunteers by the Government of India even when they perform duties similar to other government workers. To continue and perpetuate such injustices would not only affect the morale of ASHA workers but will also jeopardise the public health system.” DAKU accuses both the state and central government of their apathy towards the concerns of ASHAs.

Noormah’s case has triggered many of her colleagues to speak out against the ‘system’ they have been subject to. It has unified them and left them wondering if their contribution is even recognized. “What safety nets has the government put in place for us except for saying Corona Warriors?,” asks Sapna, an ASHA worker based in Gautam Nagar region.

“Sarkaar ne sirf hamara istemal kiya hai, hamara khayal nahi kiya (The government has only used us. They haven’t bothered to care about us),” says another ASHA based in Uttam Nagar. Most of the ASHAs feel dejected and cheated by the government.

However, Noormah’s case is not the only case but several ASHAs in several Indian states died either due to Covid-19 infection or mishaps such as road accidents and even exhaustion while performing their healthcare duties.

The Government of India in 2005 launched the National Rural Health Mission (NRHM). According to the NRHM’s mission document, “The Goal of the Mission is to improve the availability of and access to quality health care by people, especially for those residing in rural areas, the poor, women and children.”

ASHAs or say, the cadre of frontline health workers, were the one of the most important components that acted as an interface between the community and public health system. As of 2020, there were a total of 10,47,324 ASHA workers across the country, of which 6,025 are in Delhi.

Before the pandemic began, the primary role of ASHAs ranged from ensuring the antenatal, natal and postnatal services to women to counseling on family planning and nutrition to safe abortion to escorting or accompanying the pregnant female to hospital for institutional delivery.

Their role also includes creating awareness on institutional delivery, potential danger signs and complications during pregnancy, delivery and postpartum period and mobilizing the community towards increased utilization of the existing health services.

However, since the pandemic, their roles and responsibilities have increased manifolds and now also comprises door-to-door COVID-19 surveys, distributing medicine and ration kits to the needy, measuring and maintaining record of oxygen saturation, monitoring containment zones and spreading awareness about vaccines.

“Humen na koi training mili, na suraksha ke liye koi saman. Doctron ko kam se kam mask, PPE kit wegerah mila, hum logon ko kuch bhi nahi. Bus, bhej diya gaya border par ladne bina hathiyar ke (Neither were we trained nor did we get any equipment.

Doctors were given masks, PPE kits and other essentials but we weren’t given anything. We were just sent to the border to fight without weapons), says Baby Kumari, comparing the plight of ASHAs to the unarmed soldiers on the border left to fight the enemy.

As per the NRHM guidelines, ASHAs are ‘honorary volunteers’ which explicitly means they are not entitled to a monthly salary. “Initially when the program was introduced ASHA’s workload was supposed to be two-three hours per day or four days a week.

But gradually it has turned into a full time role and the government must intervene for them,” says an Auxiliary Nurse Midwives (ANM). ASHAs, ANMs and Aaganwadi workers together have been at the forefront of COVID-19 response in India.

“If ASHAs are not well off in the system, the system can’t function well,” she adds. Several studies have evaluated the functioning of these community health worker programs such as ASHAs pertinent to the performance of the overall public health system.

The efficient contribution of ASHAs can be substantiated by a report by the United Nations Development Program (UNDP) in 2015, that said that between 1990 and 2016, the maternal mortality ratio (measured as pregnancy-related deaths per 100,000 live births) declined by 77%. While, between 2005–2006 and 2015–2016, the coverage of four or more antenatal care visits (ANC) increased from 37 to 51%, institutional deliveries increased from 39 to 79%, and the percentage of births with a skilled attendant increased from 47 to 81%.

Still, their efforts and contributions to the system have gone unrecognized. They are overwhelmed with the tedious nature of the job and drop in income.

“I fainted in the scorching sun while on COVID duty. I had been feeling dizzy for the past few days but was forced to work. The Policeman on duty came to rescue me. He provided me with water and informed my husband. When my Husband asked the dispensary with which I had been associated for treatment and essential check-ups, the dispensary denied help.”

“It feels very bad when the seniors don’t even recognize your efforts. Since that incident, my mother-in-law asks why am I still doing what I am doing. I have no answers to give her but deep down my heart I only know that for me, it’s not only about a struggle for minimum wages but for self dependence,” she adds. Pooja’s colleagues also have similar and disheartening stories to share.

“My whole family got infected with COVID, including my 1.5 year kid. Everyone was staying home during the lockdown except me as I was on duty. So, I assume I would have only brought the infection home. My own family could not even get proper medication or any health check up. We (ASHAs) are paid a meagre sum of money, but I want to ask the government: Do you consider us less human?,” asks Poonam.

Rama Devi’s shares another story of despair and hopelessness. “All the ASHAs associated with Kewal Park dispensary were tested for COVID-19.

A few of us had been feeling low for a few days and hence, we assumed that most of us would be COVID positive. Days and days passed on but results never arrived.

Eventually, all of us were working. After a month, we were told that 6 to 7 of us out of 19 were COVID infected. Just imagine how many people would have been infected just because of us,” exclaims Rama. Several ASHA workers I met complained about the absurdity of incentive based honorariums for full time work.

They said they have seen their incomes drop between Rs 1000-3000 during the pandemic, in some cases due to the suspension of routine tasks such as immunization, pre and antenatal care and loss of incentives.

Most of these ASHAs come from very humble and marginalized backgrounds and have also been experiencing debt burdens. “Since schools are conducting online classes, I had to buy an android mobile phone for my son. It cost me around 7000 Rs. Husband was working in a wooden ply shop and had lost his income because of the frequent lockdowns.

A family of five people had to survive on little money. Today I have a debt of around 12000 Rs. Hence, I chose not to raise my voice against seniors fearing loss of job,” says an ASHA worker referring to the protest calls by ASHA unions.

According to a report titled “Female Frontline Community Healthcare Workforce in India during COVID-19” by Behanbox, “Frontline healthcare workers have reported instances of discrimination and violence both from within the community and other healthcare staff and government officials including the police during the pandemic. There have been many recorded cases of assault on ASHA workers by community members especially in Haryana, Delhi, Telangana, Uttar Pradesh ASHA workers.”

The report also revealed that the bulk of Covid tasks has impacted the physical health of workers. “Many reported loss of weight, body pain, fluctuating blood pressure and haemoglobin levels. Fear of infection and debt burden has exacerbated anxiety and stress levels, adversely impacting mental health of ASHA and Aaganbadi Workers,” said the report.

Since the ASHAs have been categorised as ‘volunteers’, neither the Centre nor the States are legally bound to pay them a minimum wage. The incentives are task-based and run under the National Health Mission (NHM), which is funded in a ratio of 60:40 between the Centre and the States. There are as many as 60 tasks for which the state can set incentives for.

It ranges from Rs. 1 from prophylactic distribution of Oral Rehydration Solution (ORS) to families with under-five children to Rs. 5000 for facilitating treatment and support to drug resistant Tuberculosis (TB) patients. Except Andhra Pradesh, Kerala, Karnataka, Haryana, West Bengal and Sikkim, ASHAs workers do not get a fixed monthly payment. And, that is one of the major bone of contention between the ASHAs and the government.

“If the Delhi government has fixed Rs. 18000 as minimum wage, why aren’t we (ASHAs) considered under it?,” asks Rama Devi. Right to minimum wages and government employee status have been a long standing demand of ASHA workers in Delhi and other states. DAKU too has been vocal about this and has been repeatedly engaging with the government through letters and meetings but nothing seems to be moving.

When asked whether the government proposes to make services of ASHA workers permanent, the Minister of State in the Ministry of Health and Family Welfare, Ashwini Kumar Choubey on March 13th last year categorically said in the Parliament, “No. Under the National Health Mission, ASHA are envisaged to be community health volunteers.”

In 2018, the Centre Government approved the ASHA benefit package that made them eligible for social security schemes implemented by the government namely, the Pradhan Mantri Jeevan Jyoti Bima Yojana and Pradhan Mantri Suraksha BimaYojana. The incentive of ASHAs per month was raised from Rs. 1000 to Rs. 2000 for routine activities.

Soon after the pandemic hit India, the Ministry of Health and Family Welfare (MOHFW) in May 2020, announced Rs. 50 lakh insurance cover under the ‘Pradhan Mantri Garib Kalyan Package Insurance scheme for all healthcare workers including ASHAs ​​in case they succumbed to COVID-19. Additionally an incentive of Rs. 1000 per month was also provisioned for ASHAs engaged in COVID-19 response, under the India COVID-19 package.

Despite announcements and provisions, many ASHAs complain that they haven’t received due incentives. Noormah’s family is an example that hasn’t received the insurance amount. Razekin continues to run pillar to post to get the insurance amount cleared.

DAKU has done a series of communications with the centre and state government over the demands. Their major set of demands includes: to immediately grant compensation of Rs. 1,00,00,000 (one crore) to the families of ASHA workers who succumbed to COVID-19 including the family of deceased Noormah Naaz, all the facilities for quarantine and health protection being provided to the permanent employees and doctors should be extended to ASHA workers and their families, ASHA workers must get minimum corona allowance of Rs. 10000 per month over and above the amount paid currently, and that each ASHA worker should be provided complete life and medical insurance cover of Rs. 1,00,00,000 (one crore).

Apart from these COVID-19 related demands, ASHAs have been also voicing for a dignified work culture that includes incentivization for newborn baby care and follow up with families for treatment of childhood illnesses, raise in incentives for encouraging family planning (at present it is Rs. 150), opening up of bank accounts of ASHAs so that their incentives can be deposited efficiently and the money reaches them directly and most importantly that compensations or incentives must be provided timely and travel allowance.

Anguished ASHAs also wrote postcards to the Prime Minister on his birthday and ahead of PM’s address to the nation i.e; Mann Ki Baat. An ASHA worker from Bhati Mines region asked, “Dear Prime Minister, Please ensure us a salary and not incentive. It’s hard to make ends meet at Rs. 3000. Can you survive on a meagre amount of Rs. 3000?”

“Dear Prime Minister, Until when should our exploitation continue? We demand government employee status. We demand our rights,” asked another ASHA worker.

Joint Platform of Scheme Workers Federation led ‘ASHA Adhikar March’ across India on September 24. Over 10 million Aaganwadi, ASHA and mid day meal workers participated in the protests, claimed the scheme workers union.

The union has also submitted a memorandum to the Prime Minister with a 17-point demand charter that included demands from regularisation of ASHAs to a dignified work environment. DAKU also handed over a memorandum of demands to the Union Labour Minister Bhupendra Yadav.

“Throughout the country community health workers are subject to exploitation. Imagine a worker working for 12-14 hours every day and the government is not even willing to ensure minimum wages.

They have worked so hard to contain the COVID infections in the interior pockets of the country. The demands of ASHAs bare minimum and they deserve all of it,” said Shweta Raj, State Secretary, DAKU.

DAKU also warned the government of the grave consequences if the demand of ASHA workers were not met in a time bound period. “If the government doesn’t listen to us, we will intensify the struggle further across the country,” said Rajeev Dimri, National Secretary, All India Central Council of Trade Unions (AICCTU).