Walking into 2021, if there was one positive to be identified with the large-scale outbreak of a pandemic in 2020 in India, and the rest of the developing world, it would have been this: a primary focus given by most governments and their executive agencies to improve healthcare services and ensure more affordable access of them for large scale populations. This has been done irrespective of the ‘fiscal limitations’ and ‘weak governance systems’ cited earlier as reasons for making healthcare a lesser priority, and an area of investment to be outsourced to the private sector.
Notwithstanding, in the context of the Central government’s own response and by most of the states, one section of frontline healthcare workers, the ASHA workers, or the accredited social health activists, responsible for ensuring last-mile delivery of essential healthcare services (in areas of reproductive care, child nutrition, etc.), received little to no support even as most of the workers were put on COVID-19 testing duties in their localities, crumbling under the weight of rising infections and insufficient infrastructure.
In an attempt to understand the working condition of most ASHAs, ANMs (auxiliary nurse midwife) and AWWs (anganwadi workers), our centre’s research team interacted with a number of medical professionals and workers associated with different urban primary health centres (PHCs) in Lucknow (Uttar Pradesh) and Pune (Maharashtra).
From the responses documented through audio-visual interviews, most ASHA workers raised serious concerns on being put on COVID-19 testing duties for weeks, preventing them from devoting time during the day to attend to pregnant women (including those in high-risk category) in their communities, which is also linked to their main source of incomes.
On average, work hours of most ASHAs increased by seven-to-eight-hour shifts, and the promised payments for extra time put into work have still not been credited into the accounts of more than 80% respondents spoken to.
Overworked and underpaid
Sarwari, an ASHA working with a PHC near Jama Masjid (Lucknow), says “Corona kal mein toh hum logo ki duty lag gai thi March se hi. Subah 8 Baje jate the; logo ke ghar jana, survey karna.. Kabhi kabar 3 baj jata tha.. Iske ilawa kabhi raat ko (maternal) case ki delivery ke vakt jana hota hai (We had our duty since March, leaving home at 8am and coming back as late as 3pm. We had no time to attend to our cases during the day so, had to rush late night for deliveries of high-risk pregnancies).”
Change in work commitments, and the scare created around the virus spread, made most ASHA workers undergo increased harassment from their own family members, who felt their vulnerability and exposure to the field, would bring the virus home, and many people within their own community refused to interact with them. This has prevented ASHAs from attending pregnant women.
Sarwari describes the trouble she faced from her own family and spouse, as her husband would often say, “Quit all this work. There is nothing in it. Just quit it. This is not how we want to earn this meagre sum of 2,000 rupees, and you don’t even get that paid in time..”
There were many instances when ASHA respondents raised concern about the lack of any consideration shown by state authorities about their own medical condition, especially a few who were pregnant themselves.
With no provision of paid or sick leaves available to ASHAs due to the deeply exploitative nature of their (work) contract with the public health system, most respondents, having no one else to take care of their children at home, had to bring their infants to the field, while conducting the surveys and exposing themselves (along with their children) to a higher possibility of contracting the virus.
Dr. Andaleep Rizvi, a medical officer in charge of a few urban primary health centres in old Lucknow, echoes the importance of ASHAs to the community health system and how their well-being, professional requirements need to be put at the centre of any healthcare policy,
“The ASHA worker is a part of the community. It is easier to gain cooperation from the patients as they already trust the ASHA as she is from the community itself…”
Rizvi elaborates, “Because we were required to go to the houses of all COVID-19 positive patients, test others from their neighbouring areas as well, community members wouldn’t trust us. It became very important for a local to come along with us during the surveys conducted. ASHAs and a few Aganwadi workers played a huge role in this, aiding us during the screening and testing process. ASHAs have truly emerged as one of the ‘unsung heroes’ from this pandemic…”
Despite the vitality of their work and presence on the field, lived experiences of many workers tell a tragic tale. Vijay Laxmi, a 35-year-old ASHA worker, narrates the details of a threatening phone call she received after her case-patient was tested positive for COVID-19.
“Doh teen din rukne ke baad voh hume phone karke ulta-seedha bol rahi thi, ‘Tumhari vajah se hum Yahan aa gae hai, humne na corona hai na kuch hai tum bas hume bewakoof (word changed) banti hai. Tum agar area mein kam karna laxmi didi toh hum tumhe bataenge. Tumne hamare sath nainsafi kari’ (After staying at the COVID-19 centre for 2-3 days, she called me and abused, saying ‘It is because of you that I am here [at the COVID centre], I did not have Corona, you have tricked us. If you work in the area or if I see you again, I will come after you. You have done a great injustice to me and my family’).”
While such resistance from many cases shocked ASHA workers on the ground at the time, even forced some of them to change their houses because of the threat faced from their own community members, in responses we received, the most disheartening experience(s) of ASHAs was at the district hospitals where they would bring a pregnant case for treatment, check-up or delivery.
Rekha describes her experience of Balrampur district hospital: “Sometimes, they (guards) didn’t let us enter, saying ‘So what if you are an ASHA! Get lost from here’… It was as if we have no respect or right to be treated with dignity any-where we would go; neither outside, nor in the hospitals… Why would a case or a community trust us?”.
Due to the crumbling infrastructure of most public-health district hospitals, many ASHAs asked their patients to have their final deliveries in ‘private’.
The meaning and the reference to the term ‘private’ requires a critical mention here. Most patients, as Rekha (and many others) explained, were even encouraged by ASHA — in absence of any medical support from the state — to have deliveries at home through ANMs, or alternatively, at private hospitals (if a patient’s family had the money to pay for it).
Dayawati, one of the AWWs, explains in detail about the scenarios of many cases in her own community that saw final maternal deliveries happening ‘privately’ at homes — without medical support/assistance or a doctor present — and in some cases, on way to a hospital (as referral transport and mobility was excruciatingly difficult during the lockdown weeks).
From the results of a recent survey done by Oxfam (India) with ASHAs across states of Uttar Pradesh, Odisha, Bihar and Chattisgarh, only around 23% of ASHAs spoke of receiving hazmat or bodysuits.
Overall, less than 75% had masks and 62% had gloves provided to do their duties at a time when ASHAs, AWWs were working with a heightened possibility of contracting the virus. Even those supplied with personal protective equipment (PPEs), didn’t receive proper training on how to use them on the field (less than 76% of total respondents said they received any training on the use of masks-PPEs).
Despite all the indignation received from a crumbling public health medical infrastructure; the failure of a government to ensure masks, PPEs for its community health workers; or, even the lack of timely payments for ASHAs working on the ground, what drove most workers to continue their labour was the voluntary will to help their own community, and those in need and in urgent care (especially the high-risk pregnant cases).
Sara adds: “Bas ek apni lagan thi ki aise musibat ke samay mein agar hum log bhi ghar pe baith jaenge toh baki logo ka kya hoga (The only thought and motivation to be out and work was that if we all sit at home even during these difficult times, what will happen to other people)”.
It is about time that a renewed focus on improving healthcare access, as highlighted from the response to a pandemic outbreak, translates into an actual vision and action plan to include (and ensure) the well-being of all its key stakeholders, especially the community health workers, and treat their instrumental work and contributions on the ground with dignity.
*Names of all respondents have been changed to protect their identity. All photographs have been taken by Jignesh Mistry (PAIGAM). More information on video-archives of interviews documented can be accessed from here.
This field-analysis is part of the Visual Storyboard initiative undertaken by the Centre for New Economics Studies (CNES) in collaboration with PAIGAM (People’s Association in Grassroots Action and Movement).
Deepanshu Mohan is associate professor of economics, and director, Centre for New Economics Studies (CNES), Jindal School of Liberal Arts, O.P. Jindal Global University. Jignesh Mistry is a senior research analyst and Visual Storyboard Team Lead, CNES. Sunanda Mishra is a research analyst with CNES. Advaita Singh and Shivani Agarwal are senior research analysts, CNES.