Unsung sheroes

ASHA (Accredited Social Health Activist) workers of India were one of the recipients of the WHO Director General's Global Health Leaders' Award during the opening session of the 75th World Health Assembly on May 22, 2022. Their outstanding contribution towards protecting and promoting health and connecting the communities with health institutions during the pandemic were recognised globally but were they feted and cheered at home? This outstanding feat hardly made any news apart from a few congratulatory Tweets! As Meena, an ASHA worker in UP, summed it up, "Kissi ne ek mithai bhi nahi khilai". Underpaid, overworked and seldom appreciated, that is the fate of these incredible community health workers in India.

Today, ASHA workers are a strong band of over one million female community health workers in India who provide primary healthcare services in the rural areas. They started off, under the National Rural Health Mission, as a new band of community health functionaries proposed to act as change agents in a village. ASHAs provide basic maternal care and immunisation for children against vaccine-preventable diseases — tuberculosis, tropical diseases, and other communicable diseases. They also play a crucial role in promotion of nutrition, sanitation, and general healthy living. One of the success stories being attributed to NRHM is a huge increase in institutional deliveries. ASHAs have achieved a remarkable feat in mobilising women from diverse communities to come to institutions. They have played a salutary role in linking communities with health institutions, educating rural communities about benefits of modern healthcare systems and eradicating, to a large extent, health-related superstitions and myths prevalent in rural societies.

During the COVID-19 pandemic and the subsequent nation-wide lockdown, ASHA workers had undertaken a broad range of tasks, risking their lives, to impart basic awareness about Covid-19 safety protocols among the general members of the public. They made door-to-door visits, assisted in contact tracing and testing. They have contributed not only towards curbing the spread of the infection but also in helping people to access treatment in both urban and rural areas. Detecting and recording Covid positive cases, often without proper personal safety gear, these ASHA workers gave a new meaning to community health service. When vaccination drives were undertaken, they covered all villages, including far flung and remote areas, to vaccinate millions of Indians. In the initial period, there was large-scale vaccine hesitancy in many pockets across the country, and the contribution of ASHA workers in persuading different sections of society to get vaccinated has been immense. ASHA workers have also worked in conflict-ridden states to provide health facilities to vulnerable citizens — mostly women and children who are invariably the first casualty. ASHA workers of Kashmir, Chhattisgarh and some Northeastern states worked day and night to bring community health service to the doorsteps of the women and children of these areas. Arati, an ASHA worker in Chhattisgarh said, "We walk 5-10 km almost daily, carrying heavy vaccine boxes, to access remote places, conduct surveys and vaccinate villagers." Zubeida, an ASHA worker in Kashmir had to battle vaccine hesitancy in her area and eventually succeeded in persuading the senior citizens to get vaccinated. Unfortunately, she succumbed to Covid-19 and left behind a family of two children and a daily wage earner husband who are still awaiting the Rs 50 lakh compensation announced by the Govt. of India for frontline workers

The ASHA workers are paid a paltry sum. The government of India, in 2018, increased the incentive package for ASHA workers to at least Rs 2,000 per month. Some states have also started giving a fixed component to ASHA workers. In Telangana, for instance, ASHAs are paid a wage of Rs 6,000 a month. In Bihar, on the other hand, ASHA workers have no fixed wage component, and get only incentives. There is a wide variation and pay disparity among community health workers of different states.

In the International journal of Medicine and Public Health (July-September 2020 issue), a study undertaken by Sadhana Meena, Monika Rathore, Pragya Kumawat and Arpit Singh in Jaipur district; reveals that majority of ASHA workers who are mostly locals, joined the service for financial reasons and a substantial number of them joined the service due to the fact that working in the health sector was considered to be socially respectable. However, some of the challenges they had to face were traveling long distances without proper transport facilities, lack of coordination with Anganwadi workers and hospital authorities with whom they have to coordinate on a regular basis, lack of funds to meet incidental expenditure while accompanying a patient etc. While their workload increased day by day, their payments became irregular and paltry. The working hours are long — eight to nine hours a day — and not having access to regular transport makes their work strenuous. They have to trudge miles for performing their daily routine activities.

ASHA workers are considered to be volunteers who receive honoraria and performance-based incentives, linked to health programmes, which are often below minimum wage. But they work mostly 6 to 8 hours on a daily basis. ASHA workers are not entitled to any of the regular social security benefits – maternity leave, pension, provident fund or Employee State Insurance (ESI). In some states, ASHA workers have been asked to apply for health insurance for which the premium would be deducted from their monthly incentives.

The WHO award has not put food on the table for these ASHA workers, they continue to languish as overworked and underpaid community health workers who have done a remarkable job in improving rural health infrastructure and putting in place a system of community and institutional linkages, leading to inter-sectoral convergence and thereby improving the rural health indicators of this country in general. The least the Union and the State Governments can do is to recognise them as Govt. health workers and pay them proper salary with incentives. That will be the biggest acknowledgement of their incredible service!

The writer is a former bureaucrat. Views expressed are personal