Since Covid-19 hit India early last year the million strong accredited social health activists or ASHA workers have been at the forefront of the public health response around the country. Just like their name ‘Asha’ implies they have brought hope to people, in both rural and urban areas, offering valuable medical advice and support.
On a routine basis, the tasks of an ASHA includes motivating women to give birth in hospitals, bringing children to immunization clinics, encouraging family planning, treating basic illness and injury with first aid, keeping demographic records, and improving village sanitation.
During the Covid pandemic they have been given numerous additional responsibilities. In Kerala for example ASHAs have worked tirelessly during the pandemic period along with the police, health workers and volunteers to help contain Covid.
“There are two types of work the ASHA does. House visits for the treatment of the home isolation of Covid positive cases. And secondly carry out vaccination drives at the Primary Health Centres” says Dr. Sri Shankar, at the Palkkulangara Health Centre under the Urban Health Mission, in Thiruvananthapuram, State capital of Kerala.
ASHA workers also engage directly with communities to check people in quarantine during Covid, carrying out household surveys along with health inspectors.
Dr Shankar points out that all ground level work, as part of the Covid response, are initiated and done by ASHA. These include organising medical treatment for those who test positive; tracing their first level contacts. If the patient is seriously ill, arranging the ambulance to shift them to a government hospital. If the patient can be maintained at his/her own home, then the ASHA would carry out a regular surveillance on that case until that patient tests negative.
On the vaccination front also at the health centers an ASHA worker’s day begins by 8am with a hectic schedule. They are responsible everything from making arrangements for the queue at the centre to setting up the vaccine in such a way that, it is administered without any delay. It’s the duty of the ASHA to see that by around 3.30 pm the batches of vaccination doses which are opened for the day, are administered without any wastages. If doses are left, then the ASHA has to run around mobilising people who were not been able to get vaccinated.
Also it is the ASHA workers, who face the public when they come with various questions and apprehensions about the effects and after effects of vaccines effects or about comorbidities like diabetes, hypertension and various other health complications.
“ASHAs work for 24 hours, round the clock. This is because a call from the Health Centre doctor, could wake them up any time even in the night to attend certain patients with severe complaints” says Dr Shankar. ASHA workers have also been trained and deployed to use portable oxygen concentrators for patients at their homes, where needed.
Despite their phenomenal contributions ASHAs, who are mostly local women trained to act as health educators and promoters, are right at the bottom of health system hierarchy, given low pay and made to work long hours. In many parts of the country they have been thrust into the frontlines by the health authorities during the pandemic with little preparation, protection or due recognition of their services
Even in a state like Kerala, known for prioritising health and women’s empowerment, the ASHAs are a disgruntled lot – reflecting both the immense stress caused by pandemic-related work as well as pent up grievances over the long-term.
Being amidst the community much of the time ASHA workers have been infected in large numbers by Covid with several deaths among them. In mid-July, according to Kerala’s ministry of health over 1747 out of a total 26,221 ASHA workers in the state had tested positive. Although health workers including ASHAs are included in the priority group for vaccination, many did not get second dose of vaccination due to vaccine shortages.
While at constant risk of exposure to Covid the ASHAs have also had to fight for the honorarium due to them for their work.
“ Every time there is a delay, we hold protests and then they pay our honorarium. Last protest was in February this year, when 2000 ASHA workers came together in front of the Government Secretariat demanding the pending honorarium for three months. We have to fight like this for all our needs, all these years”, said S. Mini, state convenor of the Kerala ASHA Workers Association.
A typical ASHA worker’s monthly income is Rs. 9000 that includes a honorarium of Rs.6000 an incentive of Rs. 2000 and Covid risk allowance of Rs. 1000. The state government provides 60% of the honorarium and the balance is borne the Central government. Before the Covid pandemic their honorarium was just Rs. 1000, which the Left Front government raised to Rs.6000. Nationally, the ASHA initiative was launched in 2006 as part of the National Rural Health Mission.
Not all the complaints of the ASHAs are against the government though. Many for example complain about the regular abuse they face from some members of the public.
“The more the educated people the worse their approach and behaviour towards the ASHA workers. On seeing us, some people look at us with contempt, as if we are spreading the Covid”, said Mrs. Surabhi Devi, an ASHA worker told Covid Response Watch.
Even those who have tested positive for Covid look down upon the ASHAs and treat them badly. Describing her field experience Mrs Surabhi Devi said “I went for a house visit of a Covid positive case to adhere a sticker at their gate as instructed by our Public Health Inspector. On the first day itself, an elderly member of the house shouted at us and removed the sticker. We reported this to the PHI and the next day, we convinced them with the help of the local police to paste the sticker at the compound wall.” It is possible, she feels, that the elderly man at the patient’s house saw the sticker as a stigma.
“We have to remain cool and composed in all situations” said Mrs. Bindu Sunil Kumar, another ASHA worker.
Ajit Lawrence is a journalist based in Thiruvananthapuram.