Palghar-based Bhakti Kini, 50, was accused by a villager of working in collusion with fraud doctors, who were charging them hefty fees

In 2005, ASHA (Accredited Social Health Activists) workers like Kini were recruited under the National Rural Health Mission (NHRM). Their job was to act as a bridge between public healthcare and communities. They are tasked with antenatal and care for newborn babies, their immunisation, encouraging family planning and treating primary illnesses. When Kini was in search of a job in 2009, the gram panchayat of Saphale encouraged women residents to join the force. Kini, who had not heard of the outfit, joined because all her friends had decided to. “We were promised Rs 500 per month, but were given around Rs 300. Frustrated, we staged protests outside Mantralaya. After that, I was paid Rs 2,000 per month. I’ve always wanted to help people, create awareness about government health policies, and protect the vulnerable from illness. This was my calling. I would go door to door, registering newborns for polio drops, looking after pregnant women, getting them the care they needed. It was a respectable job. The whole village looked at ASHA workers with immense pride…until the Covid-19 lockdown was imposed in March 2020,” says Kini, a Class XII graduate.

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At the forefront of India’s healthcare system crumbling under the weight of the pandemic, are one million ASHA workers helping the state fight the pandemic. When the nation announced that the Coronavirus outbreak was a health emergency, ASHA workers were told to step in. Their workload upped overnight because they were now expected to conduct door-to-door visits and report back on symptomatic and asymptomatic cases, carry out contact tracing that would then become data to take a decision on containment zones. “The pandemic is new to us all. Obviously, there has been hesitancy in terms of reporting actual numbers as well as taking the jab. One afternoon, a colleague went to ask if there were symptomatic patients in one house, and she got knocked over. The family falsely accused her of forcing them to get admitted into hospital. Our group ran to her rescue. She has been scarred for life,” Kini recalls. She has her own share of trauma, including this one time when she was abused by a man for colluding with fraud doctors to get patients admitted and charge them hefty bills. “He said I should be ashamed for extorting money from the poor, but I was only doing my job by reporting the sick to the government.”

Ganga Lande, 49

Despite being at the receiving end of humiliation and meagre pay, ASHA workers have continued to expose  themselves to infected people during door-to-door screening.  Ganga Lande, a volunteer with non profit Sneha, was cooped up in a one-room home in Ulhasnagar when the lockdown was announced last year. She didn’t want to venture out and become a carrier. “My husband has TB and I have  a 21-year-old to look after. I could not risk their lives,” she says. But when the NGO said that the government had promised to provide a PPE suit, face shield, mask and gloves to conduct surveys in the area, the 49-year-old was back at work on the fifth day. 

Lande joined ASHA in 2014, when her husband, who worked as a tailor, lost his job. She started at a salary of Rs 300 and says Rs 6,000 is the highest she has drawn in a month. “Our salaries are not fixed. The remuneration is incentive-based and differs each month depending on our performance. If we deliver a range of services by immunising a maximum number or kids, or registering names of pregnant women in the jurisdiction, we are paid in cash. But no matter how hard we work, the money is never enough for the effort we put in.”

Faimida Ansari, 38, says she wouldn’t have joined ASHA in September 2016, had she not lost her school certificates. The mum of four children works odd hours to conduct surveys in Bhiwandi, but wishes her salary would match the effort and time she puts in. Pics/Sayyed Sameer Bedi

The discontent got a boost with the added pressure of the pandemic. The last year has seen large-scale protests by ASHA, with members demanding better pay, access to adequate personal protective equipment (PPE) and protection from resistance and violence. 

BehanBox is a platform for in-depth, investigative and research driven journalism on gender issues. Its founder Bhanupriya Rao says that a series of reports published by BehanBox on the plight of ASHA workers during the Coronavirus outbreak nudged the government to pay heed. This study was conducted across Assam, Bihar, Haryana, Jharkhand, Karnataka, Maharashtra, Madhya Pradesh, Delhi, Telangana, and Uttar Pradesh. “On an average, work hours have increased from eight to between 12 and 15. Eighty per cent of ASHA workers, who receive incentive-based honorariums, saw their incomes drop by Rs 1,000 to Rs 5,000 during the pandemic due to suspension of routine tasks such as immunisation, pre and antenatal care,” one of the reports highlighted.

While the protests in Maharashtra have concluded, ASHA and USHA workers continue to protest low wages and are demanding regularisation of jobs, at Government JP hospital in Bhopal. This image is from a protest on June 24, 2021. Pic/PTI

Faimida Ansari, 38, a Class X graduate, says she wouldn’t have joined ASHA in September 2016, had she not lost her school certificates. “Wherever I went to apply for a job, I am asked for my Class X pass certificate. The ASHA job pays me peanuts, but it is something. My husband is unemployed and I have four kids to educate and feed,” Bhiwandi-based Ansari speaks to this writer at 7 pm. She left home for duty at 8 am, and she doesn’t know when she’ll be done for the day. Ansari, like the others, is waiting for the incentive they were promised by the central government for carrying out Covid-19 surveys. “The central government mandated a Covid-19 incentive of Rs 1,000 between January and September. Over 31 per cent of ASHA workers we interviewed said they had not received the incentive. Many respondents reported experiencing an average delay of one to six months in receiving their remuneration,” the BehanBox report added.

Vanessa D’Souza, CEO of Sneha, the Mumbai-based NGO that works with women, children and public health and safety systems with the help of ASHA, says, “Payment is a big issue for ASHA. The solution lies in the government making an allocation in the budget. I suggest alternatives like capacity building, mentoring, better supervisory support and offering constant appreciation. It will make their lives easier. A lot of them still use registers during surveys to note down details. If we empower them with technology, these frontline workers could get easy updates on the patients they need to see the next day, and record their details on a smartphone. This will make a huge difference.”

Ankur Sarin, associate professor, IIMA

“They [ASHA] are working on the frontlines without the necessary medical equipment. Rural India continues to face a disproportionately higher case load, with only about 3 per cent of the population fully vaccinated as of May 2021. Their role then becomes critical,” says Ankur Sarin, associate professor, IIMA.

To address the problem overlooked by the government, organisations like Project CHHAAV have stepped in. “It is a volunteering initiative started by a group of professors, students, and alumni of IIMA and IIMB,” adds Sarin.

Project CHHAAV was initiated in April 2021 and is now a group of over 100 volunteers from different institutions across the country. Manaswini Bhalla, associate professor, IIMB, informs, “The primary aim is to provide rural frontline workers with a kit that helps them do their job. The kit contains diagnostic equipment [oximeter and digital thermometers], PPE [5-ply face masks, face shield, and sanitizer] and a brief knowledge manual.”

The project also intends to enable the frontline workers by giving voice to their concerns. “We intend to host a series of webinars to highlight the circumstances under which they have to conduct their duties,” Bhalla says. 
 
A week after they sat on protest, Maharashtra health minister Rajesh Tope on June 23 announced that ASHA workers in the state will get an increment of Rs 1,000 on their wages and R500 monthly as COVID allowance. A smartphone and an additional allowance of Rs 200 for crowd management duty at vaccination centres is also on the cards. Around 68,000 ASHA workers across Maharashtra ended the protest since June 15, following the announcement. The state has around 71,867 ASHA workers.

Welcoming the move, Sarin says, “It is still not enough. Ideally, they are supposed to work for five hours a day. Despite the critical responsibilities that rest on them, they are designated as volunteers. This means that they aren’t entitled to minimum wages, permanent health insurance and pension, among other government benefits. Unfortunately, this reflects the larger problem of devaluing care work that women are primarily responsible for in our country.”

Ansari agrees. “We were promised an allowance last year, too. I’m yet to see it. Have still not received the amount. Why should we believe the government now?”
  
Rs 1k-Rs 5k
Drop in allowance most workers have reported during the pandemic for not being able to carry out the usual incentive-driven tasks

31
Percentage of ASHA workers who said they had not received the COVID allowance they were promised by the government, according to a report by BehanBox