The news reports across India and the world have been painstakingly broadcasting real-time data on the number of coronavirus cases which continue to rise. The government of India has been making efforts to contain its spread and prevent the loss of lives. However, one must also concede to the fact that the coronavirus pandemic has brought to the fore the otherwise hidden and customary struggles of the Accredited Social Health Activist (ASHA) workers in the country. Likewise, it has also been instrumental in bringing into focus the limited support they get from an inflexible, stratified and fragile public health system.
Under the NRHM (National Rural Health Mission) which was launched in 2005, the government of India recruited ASHA workers to connect the marginalised communities to health care. Approximately 9,00,000 ASHA workers in India, who act as a bridge between the government and people due to a human resource shortage in the health system, are working “for the nation” in these challenging times. Due to the dynamics associated with their job, they are playing multiple roles – of health care facilitators, health activists and service providers – putting their lives at risk.
For instance, an ASHA worker deployed in central Delhi for containment activities reportedly tested positive for coronavirus as no Personal Protective Equipment (PPE) kits were made available to them. In stark contrast to the risks associated in their job, ASHA workers are being paid a paltry remuneration of Rs 1000 per month for coronavirus related work, due to which they are being discouraged by their families from indulging in fieldwork, testified an ASHA worker from Maharashtra.
In fact, delays in payment to ASHA workers in Pedapalli district in Telangana has left many worried as their only source of income is this work-related incentive. Although the regular salaries of the medical staff and sanitation workers in the district have been released, ASHA workers have been hung out to dry.
Another news report stated that ASHA workers from Bengaluru had to deal with an increased workload, where instead of working 2-3 hour per day, they were now spending 4-5 hours in the field. Apart from spreading awareness about the coronavirus and conducting related surveys, the work included visiting houses, looking for cases of cholera and keeping track of immunisation, family planning, nutrition etc.
In Delhi, ASHA workers also form an important part of the medical supply chain, especially for expecting mothers, and have been assigned the responsibility of taking medicines from the dispensary and dropping it off at patients’ doorsteps when needed. These case studies corroborate with the already established fact that ASHA workers feel burdened and stressed due to the nature of their job, which has increased manifold in the current circumstances.
Since they are the ones entrusted with conducting community surveillance, it would not be wrong to presume that due to fear, mistrust and poor communication during the outbreak of the novel coronavirus and the mobile nature of the work, ASHA workers face increased resistance from communities. In a recent incident in Faridabad, an ASHA worker was beaten up when she was conducting a door to door survey related to the coronavirus.
Additionally, workers across Haryana, were allegedly cross-questioned by the community as “you come to ask about fever and cold, but has your government ever come to ask if we have food in our homes, if our stoves are burning?”, quoted the district secretary of ASHA workers in Faridabad. To put it simply, ASHA workers also have to bear the brunt of the community’s distrust with the government, apart from suffering from institutional neglect.
It becomes worthwhile to note that the struggles of ASHA workers are not confined to a particular region of India but have turned into a pan India phenomenon. Sadly, the vulnerabilities of ASHA workers have also been overlooked by one of the best performing states, Kerala. The present apprehensions and dissatisfaction of ASHA workers regarding institutional support were also in place during the outbreak of the Nipah virus in 2018. Surprisingly, the relentless denial on the part of the administration to learn from its past mistakes has resulted in ordeals for ASHA workers, which have been conveniently disregarded by state governments throughout the country.
In light of the problems faced by ASHA workers during the ongoing pandemic, it is worth mentioning that when Ebola was declared as a public health emergency of international concern, networks of community health workers played an important role in containing it’s spread in Nigeria in 2014. In response to Ebola, three significant developments required for a resilient health system were identified: improved surveillance, greater trust with the community and stronger health workforce.
It was deduced that community health workers, during the Ebola outbreak, were largely instrumental in tracing contacts, sensitising community, promoting culturally and epidemiologically protective practices and collecting data. Although India’s public health system is not realistically equipped to handle the unforeseen outbreak of coronavirus, whatever India has achieved in its fight against it is largely due to its health workers in the health system, which ASHA workers have been at the forefront of.
Interestingly, an ASHA Sangini, who oversees the work of other ASHA workers in Lucknow confirmed that three of her ASHA workers had refused to work due to the professional and personal risks associated with their job at present. According to the World Health Organisation, this attrition in health workers is often ignored in favour of reporting health outcomes and process indicators such as the number of health workers recruited.
Problems of irregular pay, lack of family support and lack of time which have been amplified in these times might add to increased attrition in the future. Therefore, it would not be wrong to say that the health system of the country is equally responsible for not only the recruitment and training of ASHA workers but also retaining them. The highly questionable role of workers of the private health sector makes a strong case for the government to make the public health system more robust and responsive to the needs of these “low-level health workers.”
Dr Ramila Bisht is a professor at the Centre for Social Medicine and Community Medicine, Jawaharlal Nehru University and Dr Shaveta Menon is an assistant professor at the Centre for Public Health and Health care administration, Eternal University.