State reassures protesting ASHAs...once again

It’s 9 in the morning, and Azad Maidan in Mumbai is alive with young cricketers getting ready for a fun weekend game. There are frequent cries of joy and anguish as the game proceeds.

Barely 50 metres away, another ‘game’ proceeds silently with 5,000 participants. This one has been going on longer, the stakes are higher and there is no end in sight for the thousands of Accredited Social Health Activists (ASHA) – healthcare workers – protesting last month at Mumbai's Azad Maidan. More than 50 women participants had to be hospitalised in the first week of the agitation, which began on February 9.

Within view of the busy road, an ASHA in her early 30s sits down on the ground. She glances around nervously, avoiding the stares of people passing by. A group of women gather around, covering her with dupattas and a chadar as she quickly changes her clothes.

A few hours later, at lunchtime, under the scorching midday sun, ASHAs gather around their colleague, Rita Chawre, each holding empty tiffin boxes, plates, and even lids. They patiently wait their turn as the 47-year-old serves them homemade food. "I manage to feed around 80-100 ASHAs protesting here," says Rita who travelled around two hours to Azad Maidan daily from Tisgaon in Thane district, along with 17 other ASHAs.

“We are taking turns to ensure no ASHA remains hungry. But we are falling sick now. And we are tired,” she adds, speaking to PARI at the end of February 2024.

After 21 days, the ASHAs finally went home on March 1 after the Chief Minister announced, “ASHA chi nirasha sarkar karnar naahi. [Government will not disappoint ASHAs].” The CM, Eknath Shinde, was speaking during the Maharashtra State Assembly’s Budget Session earlier that day.

ASHAs are an all-women workforce that provides more than 70 healthcare services. However, they are categorised only as ‘volunteers’ under the Integrated Child Development Services Program (ICDS) and National Rural Health Mission (NRHM). Hence, the payment they receive for providing healthcare services is referred to as an ‘honorarium’ and not wages or salary.

Apart from the honorarium, they are entitled to receive the PBP (performance-based payment or incentives). The NRHM states that ASHAs receive incentives based on their performance for promoting universal immunisation, services for Reproductive & Child Health (RCH) and other programmes.

Clearly the money is not enough as Rama Manatkar, one of the ASHAs, says, “ Bin pagari, full adhikari [No money only responsibilities]! They expect that we work like officers, but are not willing to pay us.”

The CM’s recent assurance – one of many official ones in the last few months –has not resulted in a government resolution (GR), at the time of this story being published. By all appearances, the ASHAs continue to have only promises to go on.

The thousands of protesting ASHAs are determined to pin the Maharashtra administration to their assurance – first made in October 2023 – to issue a GR implementing a salary hike.

“People trust ASHAs more than their own family! The health department is dependent on us,” says Vanashree Fulbandhe, also pointing out that a fundamental aspect of their role is facilitating access to healthcare services for marginalised communities. “Whenever there is a new posting of doctors, they ask: where is ASHA? Can we get her number?”

Vanashree has been an ASHA for 14 years. “I started with Rs 150…is this not like vanvaas ? When Lord Shri Ram came to Ayodhya after 14 years, he was welcomed, wasn’t he? Do not welcome us but at least provide us a maandhan [honorarium] that will allow us to live with respect and honesty?” she adds.

And there’s another demand: could they please get their salaries on time every month like everyone else? And not after delays of three months each time.

“If we keep getting delayed payments, how will we manage?” asks ASHA, Priti Karmankar who is the District Vice President ( zilla upadhyaksha ) for Yavatmal. “An ASHA provides a service but she also works for her own stomach. If she’s not paid, how will she live?”

Even their travel reimbursements for mandatory workshops and district meetings organised by the health department, are delayed by three to five months. “We still haven’t received payments for programmes assigned by the health department since 2022,” says Antakala More from Kalamb in Yavatmal. “In December 2023,” she adds, “we were on strike. They made us end it to conduct a leprosy survey. But they still haven’t paid us.” Priti adds, “We didn’t even get the payment for last year’s polio, hatti rog [ Lymphatic filariasis ] and jant-naashak [deworming] programmes.”

Rita joined as an ASHA in 2006 at a salary of Rs. 500. “Today, I get 6,200 rupees a month, of which 3,000 comes from the central government and the rest from the municipal corporation.”

On November 2, 2023, the state health minister, Tanajirao Sawant had announced that the 80,000 ASHA workers and 3,664 gat pravartaks (group promoters) in Maharashtra would get increments of Rs. 7,000 and Rs. 6,200 respectively along with a Diwali bonus of Rs 2,000 each.

A furious Mamta says, “Diwali houn aata Holi aali [Diwali has passed and it is time for Holi now] but we have nothing in our hand.” She adds, “We did not ask for 7,000 or 10,000 increment. Our initial strike in October was against the extra online work. We were told to get 100 villagers registered daily on the Pradhan Mantri Matru Vandana Yojana (PMMVY).”

The scheme, as its official website says, “provides a cash incentive for partial compensation of the wage loss during pregnancy.” A similar target was given for the newly launched U-Win app which aims to store vaccination records of pregnant mothers and children.

Earlier in February 2024, over 10,000 ASHAs had marched from Shahpur to the Thane District Collector’s office – a distance of 52 kilometres. “ Chalun aloy, tangdya tutlya [We walked all the way, our legs gave out]. We spent the whole night on the streets of Thane,” recalls Mamta.

The months of protest are taking a toll on them. “Initially there were more than 5,000 ASHAs at the Azad Maidan. Many of them were pregnant and some also came with their newborns. It was getting difficult to live here in the open and so we requested them to go back home,” says Ujwala Padalwar. She is the State Secretary of the Centre of Indian Trade Unions (CITU) and one of the organisers of the protests. Many women complained of chest and abdominal pain, others suffered from headache and dehydration and had to be hospitalised, she adds.

Once the ASHAs were discharged, they came back again to the ground, calling out in unison: “Aata aamcha ekach naara, GR kaadha! [We have only one call! Just release the GR!]."

On paper, an ASHA’s role is to bring public health services to everyone. But after years of caring for the community, they often go above and beyond. Take ASHA Mamta, who in September 2023, managed to convince a pregnant Adivasi woman from Sonivali village in Badlapur to opt for hospital delivery instead of home birth.

She recalls: “The woman’s husband refused to accompany her and said in clear words, ‘if anything happens to my wife you will be responsible’.” When the mother was in labour, “I took her from Badlapur to Ulhasnagar all by myself,” says Mamta. The mother did not survive the childbirth. The baby too had died in the womb.

Mamta explains, “I am a widow, my son was in Class 10 at that time. I left home at 6 a.m., and the mother passed away around 8 p.m. I was asked to wait in the hospital veranda till 1:30 a.m. After the panchnama was done they said, ‘ASHA tai now you can go’. Deed waajta me ektee jaau? [Am I supposed to go home alone at 1:30 a.m.]?”

The next day when she visited the village to update the records, some people including the woman’s husband abused and blamed her for the deaths. A month later, Mamta was called for questioning by the zilla samiti . “They asked me ‘how did the mother die and what error did ASHA tai make?’ If everything at the end of the day has to be dumped on our heads, then why not increase our maandhan ?” she asks.

Throughout the pandemic, the government praised the ASHA workers and hailed them “corona warriors” for their crucial role in distributing medicines and tracing infected patients from the remotest villages across the state. However, they barely received any safety gear to protect themselves from the virus.

Manda Khatan and Shraddha Ghogale, ASHA workers from Nandivali Gaon in Kalyan recall their pandemic experience, “Once, a pregnant mother tested positive for covid after the birth. When she learned that she was infected with the virus, she panicked and ran away [with the newborn child] from the hospital.”

“She thought she [and her baby] would be caught and killed,” says Shraddha. Such was the fear and misconception around the virus.

“Someone told us that she was hiding in her home. We rushed to her house but she had locked the doors,” says Manda. Fearing that she would take some wrong steps, they stood outside her house until 1:30 a.m. “We asked her, ‘Do you love your baby or not?’ We advised her that if she continued to keep the baby close to her, she would end up infecting it and would put the infant’s life at risk.”

After three hours of counselling, the mother opened the doors. “The ambulance was on standby. There were no other medical officers or gram sevaks , just the two of us.” A teary-eyed Manda narrates, “Before departing the mother held my hand and said, ‘I am leaving my child behind because I trust you. Please take care of my baby.’ For the next eight days, we went to her home daily to bottle feed the newborn. We would show her the baby over video call. Till date, the mother calls us and thanks us.

“We distanced ourselves from our own kids for a year,” says Manda, “but we saved the children of other people.” Her child was in Class 8 while Shraddha’s was barely 5 years old.

Shraddha remembers when people in her village would shut their doors. “They would run away seeing us in personal protective equipment (PPE) kits thinking that we had come to catch them.” Not only that, “We would wear the kits for the whole day. Sometimes we had to change four in one day. Our face had turned black wearing them for hours. We would walk with them in the sun. It would itch and feel like a burning sensation on our skin.”

Manda interrupts and says, “But PPEs and masks came in much later. For most of the pandemic period, we would wrap our pallus and dupattas while moving around.”

“So, our lives did not have value then [during the pandemic]?” asks Mamta, “Did you give us some different kavach [protection] to battle corona? You [government] gave us nothing when the pandemic started. When our ASHA tais started getting covid, they faced the same fate as the rest of the patients. Even when the vaccines were at the trial stage, ASHAs were the first to volunteer.”

At one point in her life, Vanashree Fulbandhe had almost decided to quit being an ASHA. “It started to take a toll on my mental and physical health,” she says. The 42-year-old looks after a population of more than 1,500 people in Nagpur district’s Wadoda village. “I remember once I was in extreme pain due to kidney stones. I had tied a cloth around my waist and was still working.”

A patient and her husband came to Vanashree’s house, “She was a first-time mother. They were nervous. I explained to them I was not in a condition to do anything but they insisted that I be present during the birth. It was difficult to say ‘no’ so I went along with them. I stayed with her for two days in the hospital until the baby was born. Her relatives would see the cloth tied around my waist and jokingly ask me, "Is it the patient's delivery or yours!”

She recalls her routine during the lockdown when she would complete her ASHA duties and deliver food to patients in isolation. “It eventually took a toll on my health. I had very high BP for many days and I thought maybe I should quit.” But Vanashree’s aunt reminded her that “what I am doing is punya [good deed]. She said two lives, [of the mother and child] depend on me. I should never leave this job.”

As she narrates the story, Vanashree briefly looks at her phone. She says, "My family keeps asking when I will return home. I came here with Rs. 5,000. I barely have Rs. 200 now.” She hasn’t received her monthly honorarium since December 2023.

Purnima Wase, an ASHA from Nagpur’s Pandhurna village recalls a critical situation. “I had assisted an HIV positive woman in her childbirth. When people at the hospital found out she was HIV positive,” says the 45-year-old worker, “they acted as if it was a big thing. I told them, ‘When I, being an ASHA, delivered the baby without any equipment other than gloves and my own scarf, why should you act like this?’”

An ASHA since 2009, Purnima looks after a population of more than 4,500.  “I am a graduate,” she says. “I get so many job offers. But, it was my decision to become an ASHA and I will continue to be an ASHA all my life. Whether I get money or not, agar mujhe karni hai seva to marte dum tak ASHA ka kaam karungi [Since I wish to serve, I will continue to be an ASHA until my death].”