In fight against Covid, ASHA corps toils on with little hope of recognition

Critical to the Covid-19 fight at community level, they remain undervalued and identified only as volunteers

India’s war against the coronavirus pandemic at the community level has rested squarely on the shoulders of its army of over a million accredited social health activists (ASHAs). They have been tasked with generating awareness about Covid-19 safety protocols, conducting door-to-door surveys to identify people with symptoms of the virus, visiting quarantined patients and more.
 

Constituted under the National Rural Health Mission NRHM in 2005, this critical cog in the wheel of India’s public health system, however, remains disempowered, undervalued and overworked, and is officially recognised as merely “voluntary”.

According to the National Rural Health Mission (NRHM), ASHAs across India perform 43 duties — from providing primary healthcare and promoting toilet construction to immunisations and taking pregnant women to hospital for deliveries. Covid duties have been added to their workload. For all of this, they are given a monthly salary that ranges from Rs 2,000 to Rs 6,000, with added cash incentives per patient for institutional deliveries, sterilisation, immunisation and so on.
 

In the early days of the pandemic, at least 30 ASHAs died of Covid, estimates the National Federation of ASHA Workers (NFAW). “We’ve been fruitlessly demanding at least Rs 10,000 as risk allowance in addition to the government-mandated minimum wage of Rs 18,000 per month,” says Vijay Lakshmi of NFAW. Instead, while some states like Delhi have given a meagre Rs 1,000 a month for Covid duty, ASHAs in other states continue to work without any extra incentive. Consider these testimonies:
 

• “At least ten ASHAs have tested positive in my block. Not only have they not received little help from the government, but they’ve also been shunned out by their neighbours who fear they might be infectious even after they have finished quarantine,” says Sunita Kumbhar, block ASHA facilitator in Shirala Block, Sangli district, Maharashtra.
 

• “Our workload has doubled during Covid, but salaries haven’t increased,” says a Bengaluru-based ASHA who does not wish to be named.
 

• “When conducting door-to-door survey, I’m not just afraid of contracting an invisible virus, but also of the abuses and curses that people sometimes heap on me when I ask if they’ve recently travelled outside the district and if so, followed quarantine protocols. They’re scared to tell me and I’m scared of them,” says Seema Devi, an ASHA in Lucknow district, Uttar Pradesh.

 

Seher, a women’s collective for better health and rights and an operational unit of Delhi-based Centre for Health and Social Justice, has been monitoring the condition of ASHAs in Karnataka, Madhya Pradesh and Jharkhand. “ASHAs face multi-layered challenges,” says Sandhya Gautam who heads Seher. “They are all women, who often belong to disadvantaged communities, and their work is undervalued and poorly paid.”
 

These issues have been exacerbated by the pandemic and lockdown. ASHAs in many states have reported reduced incomes during the lockdown as much of it is based on performance of tasks like immunisations, sterilisations and institutional deliveries. Public-health movement Jan Swasthya Abhiyan’s Bihar chapter estimates that immunisation programmes and institutional deliveries are down by at least 50 per cent, resulting in loss of income for ASHAs.
 

NFAW contends that although they are expected to be at the frontlines, ASHAs have received only the barest minimum of training of Covid protocols and scarce protective gear, especially in the early months of the pandemic. In Bihar, ASHAs in districts like Madhubani, which saw the biggest influx of returning migrants, allege they were given at a time a single glove instead of a pair.
 

“Moreover, since they only have the status of volunteers, the government has not been forthcoming in providing aid and succour at times when ASHAs have fallen ill,” says Gautam. “We know of two ASHAs in Karnataka and Madhya Pradesh who have tested positive but not received any support from the government.”
 

Kumbhar says that when an ASHA became ill in her block, it was her colleagues who got together to support her family financially and emotionally. Moreover, the Rs 50 lakh cover the government has declared for those who die on duty in the fight against Covid-19 does not extend to the cost of hospitalisation and treatment, which these women can ill-afford. “Consequently, we’ve observed ASHAs forced to take control of their own safety — one actually started sleeping in the cattle shed to avoid exposing her family in their single-room home,” says Gautam.
 

With winter now in north and central India, ASHAs, who must wash their clothes after a day of work in the community, are encountering a fresh practical problem. “Many ASHAs we know are not being able to manage washing their woollens every day,” says Shakeel, doctor and Bihar convener of Jan Swasthya Abhiyan.
 

In early October, when ASHAs in Madhya Pradesh struck work for two days to protest their working conditions, another issue came to light. “As we are volunteers, we don’t get paid vacation days,” says an ASHA from Bhopal who wishes to stay anonymous. “During the pandemic, we’ve been compelled to work 24x7, even on Diwali and Sundays.”
 

Yet, these gritty foot soldiers have accomplished critical tasks and targets during the pandemic. UP’s 160,000 ASHAs have tracked over 3 million migrant returnees across the state. Delhi’s ASHAs have not only performed door-to-door surveys, they have also visited Covid patients under home quarantine to ensure they are receiving proper treatment. Kerala’s success in controlling the spread of the pandemic has been partly attributed to the efforts of ASHAs who have immediately alerted the health department about suspected cases.
 

“Regularise our work, salary and working conditions,” says Suman Pujari, state president of the Maharashtra ASHA Union. “It is the best way to acknowledge our contribution.”