Bihar has been using its large workforce of Accredited Social Health Activists (ASHAs) towards its public outreach efforts during the ongoing pandemic. ASHAs are the frontline workers who act as an important interface between the community and the public health care system in rural areas. They live with the same communities they mostly serve and, therefore, generally have local wherewithal. As the country remains in lockdown, with citizens restrained from stepping outside their homes, a large army of ASHAs makes its way every day between 7-8 am in the morning, in their assigned wards, to perform a number of assignments.
Navigating private and public spheres in a mostly patriarchal society has made their circumstances aggravating. When Seema Devi*, an ASHA based in Rampur Jalalpur panchayat in Samastipur district of Bihar, mentioned to her husband about her assigned work, he did not want her to leave the house.
Despite her husband’s non-cooperation, every day, Seema wears her light pink sari (ASHA’s formal attire) and visits around 25 households, a target which she has set for herself. “I am supposed to do this. Even if I am scared, I cannot step back,” she says. “More than myself, I am afraid of transmitting the infection to my children and my mother-in-law,” she added.
ASHAs have been assigned a number of tasks during the ongoing pandemic. “On a normal day, in addition to distributing posters, we are supposed to trace the contacts of COVID-19 patients. We also have to find out if any person in our ward has travelled outside or has come from somewhere recently,” says Seema. After completing the survey, she is required to hand over the data to her supervisor at around 3 pm, which will be submitted to the nearby primary health centre (PHC).
Moreover, they have been instructed to screen all households to identify any persons showing symptoms of the coronavirus infection, in the desired format provided by the state. ASHAs are also supposed to paste an A3 size poster at the doorstep of each household within their respective wards, which contains information on symptoms and safety measures for COVID-19.
Providing further details of her daily tasks, Seema says, information related to travel history and symptomatic cases is channelled differently. “In case any person has a travel history or shows symptoms of the infection, we have to immediately report to the Auxiliary Nurse Midwife (ANM), who in turn, reports to the block office,” Seema adds. A medical team from the block office is then supposed to arrive, test the suspected patient and take further necessary actions. ASHAs are also required to show the visiting team to the suspect’s house. In addition, ASHAs have been working with their respective ward heads, called mukhiyas, to distribute items such as handmade face-masks and a bar of soap to each household.
With the doctor-population ratio already at a poor 1:3207 people in Bihar (which is less than the country’s average of 1:1456), most rural medical practitioners have shut their doors during the outbreak and the already dilapidated public health care system remains strictly focused on coronavirus crisis management. In this scenario, ASHAs have also been working as an important point of contact for the community for the ‘other’ issues, as well such as disease management in tuberculosis and other diseases, maternal and child health, family planning etc.
Moreover, they sometimes have to face a few non-cooperative community members on the field. “We hear comments like, ‘She is not here to do a survey, she will give names to PHC and they will take us away to those terrible centres’,” said Hira Devi, another ASHA of Samastipur district. Some households have put a ‘no entry’ board outside their house, refusing to communicate with ASHAs. “Some of the tolas are even more non-cooperating, they do not even open the door,” she mentioned.
Essentially, ASHAs have become the first point of contact for a suspected patient. So far, they have been venturing out without adequate protection. When they demanded the minimum safety gear, ASHAs were asked to continue working. As members of the health department, they should understand the need of the hour, they were told. “When I asked for face masks to enable me to perform these activities in the field, the ASHA facilitator said, ‘We will give it to you once we receive, and we cannot commit a timeline’,” says Simala Devi, a 45-year-old ASHA. They have received instructions to maintain a safe distance and not sit anywhere in the field. “I sometimes touch my face unconsciously and begin searching for water to wash my face,” she mentioned. “After coming from the field, I go straight to the bathroom, located in the backyard, to bathe, change clothes. Only then do I enter the house,” she says. Many ASHAs, including Simala, fall in the high-risk category because of their age and/or other health conditions.
Fortunately, no ASHAs have succumbed to COVID-19 yet in Bihar. However, it is important to note that ASHAs have not been trained or appointed to work in these crisis situations. Apart from a medical insurance cover of Rs 50 lakh per person, the remuneration for ASHAs has been increased by an additional Rs 1000 per month for the three months during the crisis. “Sometimes, I feel proud to serve the community in this unprecedented situation, but I am still risking my life. What will I do with those Rs 3000 if I don’t stay alive and healthy?” Simala Devi asks.
Perhaps, these important women community health workers are so low in the chain of the health bureaucracy that their efforts and community-leadership neither get highlighted nor recognised. However, the ongoing crisis should open our eyes to not only re-shape and re-design our future which includes ‘nutrition for all’ and ‘healthcare for all’, but it should also do so in a humane way where the efforts of our last mile workers are recognised and appreciated both socially as well as economically.
*Names have been changed for confidentiality reasons.
Saroj works as a public health consultant in Bihar. Nikhit Agrawal is an Anthropology PhD candidate at UCLA.