ASHA workers: struggle for survival in shadows outside WHO spotlight

New Delhi, May 31 (PTI) Come rain, sun, hail or indeed a contagion, the band of women who form the bedrock of India’s rural healthcare system slog on, anonymous, underpaid and mostly unsung – until last week when the WHO honoured them for their efforts in controlling Covid.

For the 10 lakh Accredited Social Health Activists (ASHA) volunteers who administer medicines, vaccines, first aid, offer health advice and a myriad other services across the length and breadth of India, the WHO recognition is just the global spotlight they need.

But their battle against low payments, no facilities and erratic schedules continues. And because they are women, so does the tightrope walk between their homes and their jobs.

Like for Sailendri, 42, an ASHA worker from Basti in Uttar Pradesh who wakes up at 3 am every morning, finishes her chores at home and then joins her colleagues in going home to home. Her primary worry is how to make ends meet.

"The government must give us a fixed income. There is so much work. Do authorities see the work we put in? We have served the people so faithfully but got only empty praise,” she said, unaware that ASHA workers like her have been honoured on an international platform.

"We get Rs 10,000 per month at most. How are we expected to support ourselves with that money with prices going up every day? Also, the personal sacrifice we make by keeping our work before our family… Who values that?" Sailendri, who has been an ASHA volunteer for 16 years, added in a phone interview to PTI from her home in Basti.

Sunita Sinha, an ASHA worker from the Sabour block of Bhagalpur district in Bihar, agreed.

Echoing Sailendri’s resentment, she said there are days when they even have to take a patient to hospital.

"There is no conveyance and we have to manage everything on our own. Also, we work under so much pressure. There have been days when we spend the whole day walking and don't sit for five minutes. But this is not acknowledged.” During the long months of lockdown, she went from house to house to tend to patients without any concern for herself, Sunita said.

"I remember one instance... we were running low on masks so we sanitised clothes and made masks to ensure protection for everyone possible. Even now we are encouraging people to get vaccinated. We have helped raise awareness on vaccination since the day the vaccination drive started," she said from Sabour.

ASHA workers are the first and sometimes only point of contact for millions of villagers and the healthcare system. They earn money through task-based incentives under the National Health Mission (NHM), which is funded in a 60:40 ratio between the Centre and state government. All the ASHA workers PTI spoke to said they don't earn more than Rs 10,000 per month.

Poonam Muttreja, executive director, Population Foundation of India, noted that there are major differences between the pay scales of regular frontline workers and those recruited on a contractual basis under the National Health Mission.

"During the COVID-19 pandemic, ASHAs continued to work in fragile settings despite receiving resistance from communities. A study conducted by the Population Foundation of India during this period showed that the fear of getting infected by COVID-19 among people kept many away from accessing services at health facilities," she said.

She added that the government had introduced a performance-based payment method to support ASHAs. However, ASHA incentives are primarily centred on activities relating to reproductive and child health.

“ASHA incentives get significantly impacted in states with low total fertility rates and higher usage of private health care facilities," she said.

Compensation given to ASHAs differs across states and only a few have introduced fixed monthly remuneration in addition to the incentive package, Muttreja added.

Stressing that the disbursement of incentives needs to be timely and regular, she said ASHAs have a wide-ranging experience working with the community and the health system and a clear career progression path is imperative for them.

According to Akhila Sivadas, executive director at the Centre for Advocacy and Research, a non-profit organisation, the time has come to recognize the indispensability of ASHA workers.

“An all-out effort must be made to ensure that every process related to ASHA starting from recruitment, appointment, training, remuneration and the right to appeal and redress must be streamlined to ensure that they feel both respected and given the due that they are entitled to,” Sivadas said.

As the struggle for acknowledgement and better pay structures continues, Priyanka Kumari from Lakhisarai in Bihar said the biggest award for her is the satisfaction she sees in the eyes of her patients when they get treated.

"If I wanted to earn money I would have done something else but this is a noble profession for me and I keep that in mind whenever I feel inconvenienced," the 41-year-old told PTI.

”ASHA, a Hindi word, which means hope, are the more than one million accredited female health workers in India, who have been honoured at the 75th World Health Assembly for their crucial role in connecting the community with the health system to ensure primary health care services,” the WHO said.