Counting cows, not rural health indicators

On a bright and sunny day, 39-year-old Sunita Rani is speaking to a group of around 30 women, exhorting them to come out in large numbers and sit on an indefinite strike for their rights. “Kaam pucca, naukri kacchi  [Assured work, unsure pay],” Sunita hollers. “Nahin chalegi, nahin chalegi  [This can’t go on, this can’t go on]!” the other women chant in unison.  

On a patchy lawn outside the Civil Hospital in Sonipat town, off the Delhi-Haryana highway, the women, dressed in hues of red – their uniform in Haryana – sit on a dhurrie and listen to Sunita as she lists the woes they know all too well.

The women are all ASHAs, Accredited Social Health Activists, foot-soldiers of the country’s National Rural Health Mission (NRHM), a critical link connecting India’s rural population to the country’s public healthcare system. Over 1 million ASHAs work across the country, and are often the first healthcare worker available for any health-related needs and emergencies.

They are required to perform a mind-boggling array of 12 primary tasks and over 60 sub-tasks, ranging from disseminating information about nutrition, sanitation and infectious diseases to tracking treatment of tuberculosis patients and maintaining records of health indicators.

They do all this and more. But, says Sunita, “What gets left behind is what we are actually trained for – improving maternal and neonatal health statistics.” Sunita works in Sonipat district’s Nathupur village, and is one of three ASHAs in the village taking care of a population of 2,953 people.  

Besides ante- and postnatal care, ASHAs are community health workers who also generate awareness about government’s family planning policies, contraception and the need for spacing pregnancies. They have been central to bringing down infant mortality rates from 57 deaths per 1,000 live births in 2006 – when the ASHA programme was launched – to 33 deaths in 2017. Between 2005-06 and 2015-16, the coverage of four or more antenatal care visits increased from 37 per cent to 51 per cent, and institutional deliveries increased from 39 per cent to 79 per cent. 

“Despite the good work we have done and can do, what we end up doing is filling survey after survey,” Sunita adds.

“Every day we have to submit a new report," says Neetu (name changed), 42, an ASHA worker based in Jakhauli village. "One day the ANM [auxiliary nurse midwife, who ASHAs report to] asks us to survey all women in need of antenatal care, the next day we collect information on the number of institutional deliveries, the following day we have to record everyone’s blood pressure [as part of a national programme for control of cancer, diabetes and cardiovascular disease]. The day after that we are asked to do the booth level officer’s survey for the Election Commission. It never ends.”

Neetu estimates that she has put at least 700 weeks into this work since she was inducted in 2006, with holidays only for sickness or festivals. She looks visibly exhausted, even though there are nine ASHAs in her village of 8,259 people. She had arrived at the site of the strike an hour late, after finishing an anaemia awareness drive. The list of door-to-door tasks that ASHAs can be called upon to do at any time arc from counting the number of pucca houses in a village to counting cows and buffaloes in a community. 

“In just three years, since I became an ASHA in 2017, my work has increased three-fold – and almost all of it is paperwork,” says Chhavi Kashyap, a 39-year-old ASHA worker who has come to participate in the strike from her village, Bahalgarh, eight kilometres from the Civil Hospital. “When we finish with every new survey the government throws at us, we have to begin our actual job.”

For 15 years after she was married, Chhavi did not step out of her house unaccompanied, not even to the hospital. When an ASHA facilitator came to her village in 2016 and conducted a workshop on what ASHAs do, Chhavi wanted to enlist. After these workshops, the facilitators shortlist the names of three married women between the ages of 18 and 45 who have studied at least until Class 8 and who are interested in working as community health volunteers.

Chhavi was interested and eligible, but her husband said no. He is on the nursing staff team at a private hospital in Indira Colony in Bahalgarh, and works the nightshift two days a week. “We have two sons. My husband was worried about who would take care of them if both of us had to be out together,” Chhavi says. A few months later, when money was tight, he asked her to sign up. She applied during the next recruitment drive and was soon confirmed by the village’s gram sabha as one of five ASHAs for Bahalgarh's 4,196 residents.

“There’s just one rule we, as a couple, have. If he’s on nightshift, and I get a call that a woman has gone into labour and needs to be escorted to the hospital, I can’t leave the kids and go. I call an ambulance or ask another ASHA to fill in,” Chhavi adds.

Escorting pregnant women in labour to hospitals is a part of the many tasks ASHA workers juggle every week. “Last week, I got a call from a full-term woman saying she was having labour pains and wanted me to take her to the hospital. But I couldn’t leave,” says Sheetal (name changed), an ASHA worker from Badh Khalsa village in Sonipat’s Rai tehsil adds. “That same week, I was asked to conduct an Ayushman camp,” 32-year-old Sheetal adds, referring to the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana. Stuck at the camp with a bagful of forms and records of everyone in her village who was eligible for the government's health scheme, she was under orders from the ANM she reports to prioritise Ayushman Yojana work over all other tasks.

“I had worked hard to build trust with this [pregnant] woman ever since she got married and came to the village two years ago. I was with her – right from convincing her mother-in-law to allow me to counsel her about family planning to convincing her and her husband to wait for two years to have a baby, and all through her pregnancy. I should have been there,” Sheetal adds. 

Instead, she spent half an hour on the phone trying to calm an anxious family that didn’t want to go without her to the doctors. In the end, they went in an ambulance she arranged for them. “The cycle of trust we build gets disrupted,” Sunita Rani says.

When ASHA workers finally get down to doing their job, they often work with one hand tied. Drug kits are usually not available, nor are mandated items such as paracetamol tablets, iron and calcium tablets for pregnant women, oral rehydration salts (ORS), condoms, oral contraceptive pills and pregnancy kits. “We aren’t given anything, not even medicines for headaches. We make a note of the requirements in each house, including who takes what form of contraception, and then request the ANM to give it to us,” Sunita says. Government records online bear this out – just 485 drug kits were issued for 1,045 ASHA workers in Sonipat district.

Often, ASHA workers go empty-handed to their community members. “Sometimes they’ll give us iron pills but not calcium, which pregnant women should ideally have together. Sometimes they give us only 10 pills per pregnant woman, which finish in 10 days. When the woman comes to us, we have nothing to give her,” Chhavi explains.

At times, they are given products of poor quality. “After months of no supply we get boxes full of Mala-N (a combination hormone oral contraceptive pill) one month before their expiry date, with orders to distribute them as soon as possible,” Sunita says. The feedback from women who use the Mala-N, diligently recorded by ASHAs, is seldom taken into account.

By afternoon on the day of the strike, 50 ASHA workers have gathered for the protest. Tea is ordered from a stall next to the outpatient department of the hospital. When someone asks who’s paying, Neetu jokingly says it can’t be her as she hasn’t been paid for six months. ASHA workers are ‘volunteers’ as per the NRHM’s 2005 policy, and their payment is based on the number of tasks they complete. Only five of the numerous tasks assigned to ASHAs have been categorised as 'regular and recurring'. For these, the central government agreed in October 2018 to a total monthly amount of Rs. 2,000 – but the payments are rarely made on time

Beyond that, ASHAs are paid per task completed. They can get a maximum of Rs. 5,000 for administering medicines to drug-resistant tuberculosis patients for a period of six to nine months, or just Re. 1 for distributing an ORS packet. Family planning incentives are tilted in favour of female sterilisation procedures over spacing methods. For facilitating a tubectomy or vasectomy, ASHAs receive an incentive payment of Rs. 200-300, whereas they receive a mere Re. 1 for each packet of condoms supplied, or for oral contraceptive pills and emergency contraceptive pills. There is no payment for general family planning counselling, which is a necessary, tedious and time-consuming task for ASHAs.

After several nationwide and regional strikes, different states have started paying their ASHA workers a fixed monthly stipend as well. There are country-wide variations, from Rs. 4,000 in Karnataka to Rs. 10,000 in Andhra Pradesh; in Haryana, since January 2018, each ASHA gets Rs. 4,000 as a stipend from the state government.

“According to the NRHM policy, ASHAs are supposed to work three to four hours a day, four to five days a week. But no one here can remember the last time they took a day off. And how are we being financially supported?” Sunita asks loudly, opening the floor to discussion. Several women speak out. Some haven’t been paid their monthly stipend from the state government since September 2019, others haven’t received their task-based incentives for eight months. 

Most, however, have lost track of how much they’re owed. “Money comes from two different sources – the state government and the central government – in staggered amounts, at different times. One forgets which payment is due when,” Neetu says. There are personal repercussions to this delayed, paltry payment of dues. Many face taunts at home for doing a job with odd and long hours but no proportionate payment; some have left the programme under family pressure.

Two-and-a-half hours into the strike, their demands are clear: a health card for ASHA workers and their families entitling them to services at private hospitals empanelled with the government; ensuring they are eligible for pension; separate pro formas for their tasks instead of a two-page cluttered sheet with minuscule columns; and a cupboard at the sub-centre so they aren’t compelled to store condoms and sanitary napkins at home. Three days before Holi, Neetu's son had asked her about the balloons she had in her cupboard, referring to the condoms she stored there.

And mainly, ASHAs believe their work must be treated with respect and recognition. 

“At to the delivery rooms in many hospitals in the district, you’ll see a sign that says, 'No entry for ASHAs'," Chhavi says. “We accompany women for deliveries in the middle of night, and they ask us to stay because they’re not confident enough and they trust us. But we’re not allowed inside. The hospital staff says, 'Chalo ab niklo yahan se [Clear out now]'. The staff treats us like we’re lesser than them,” she adds. Many ASHA workers end up staying overnight with the couple or family, even though there is no waiting room at many primary and community health centres.

It is nearly 3 p.m. at the protest site, and the women begin to get restless. They have to get back to work. Sunita rushes to wrap up: “The government should recognise us officially as employees, not volunteers. It should take away the burden of surveys so we can do our work. It should pay us what we are owed.”

By this point, many ASHAs are packing up. “Kaam pucca, naukri kacchi,” Sunita hollers one last time. "Nahin chalegi, nahin chalegi," she hears back, louder than the first time around. “We don’t even have time to sit on a hartal [strike] for our rights, we have to schedule our strikes between camps and our surveys!” Sheetal says with a laugh as she covers her head with her dupatta, ready yet again to embark on her round of daily home visits. 

PARI and CounterMedia Trust's nationwide reporting project on adolescent girls and young women in rural India is part of a Population Foundation of India-supported initiative to explore the situation of these vital yet marginalised groups, through the voices and lived experience of ordinary people.  

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