* They performed these Covid-19 duties in addition to their regular work which included assisting deliveries, immunisation drives, sterilisation camps and staffing the PHCs
* Several of them died during Covid-19 duty as reported in different regional newspapers. However, insurance benefits were not provided to family members in most states
* Every village has a team of five ASHA workers and, along with anganwadi workers, they are helming the vaccination drive in the villages and urban slums
* Now that the spotlight is on ASHA workers, they hope that their problems will be addressed. Many, for one, are still to be vaccinated
Mamata Devi (37) is waiting for her second Covid-19 vaccine dose. “I have been administered the first dose and am awaiting the next one. Anganwadi workers and PHC staff have been given the vaccine by a team that came from a city, but I am not aware how it is going to be for the others in the village,” says Mamata, an Accredited Social Health Activist (ASHA) worker from Harhua in Varanasi, as she makes her way to the Primary Health Centre (PHC) in her village.
She is among the million-strong ASHA workers who form the backbone of the country’s sprawling healthcare system on the ground, and they have been at the forefront in the battle against Covid-19.
She knows the importance of the vaccine. The whole of last year, Mamata and her colleagues were on the field, conducting surveys for contact tracing and were engaged in community surveillance as the pandemic raged on. Their work during the pandemic involved registering the address and verifying the IDs (details such as Aadhaar card numbers and names) of migrant workers returning to the villages in the early months of the pandemic, and following up on those with travel history who took ill.
It was risky and painstaking work. They performed these Covid-19 duties in addition to their regular work which included assisting deliveries, immunisation drives, sterilisation camps and staffing the PHCs. A year on, those like Mamata are still waiting for the extra remuneration promised to them for Covid-19 duty. The ministry of health and family welfare had, in an April order, directed states to ensure ASHA workers got additional incentives for Covid-19 related work and provide them with safety equipment to carry on their duties. Their work involved everything from testing, contact surveillance and quarantine supervision.
“We were lucky that way,” says Mamata. “Not many fell sick in the village. Now you can’t even tell as everything has opened up. Last year was really difficult,” she recalls.
ASHA workers are the foot soldiers fighting the Covid-19 pandemic in India, performing the laborious task of collecting data and taking care of the sick at great risk to themselves. But they have been left in the cold when it comes to remuneration, permanent status as a government employee and job benefits. They do not get minimum wages as volunteer workers. Several of them died during Covid-19 duty as reported in different regional newspapers. However, insurance benefits were not provided to family members in most states.
On March 1, India launched the world’s biggest vaccination drive to halt the surging virus. Frontline workers were vaccinated across the country a month before the mass vaccination drive began. The Union health ministry has set the target of vaccinating 500 million people by July. While hospitals in the metropolises and cities have begun to witness crowds of people coming in to take the vaccination, the villages have largely remained quiet as they await their turn. During question hour in Parliament last month, the government said it would utilise the existing infrastructure of the Universal Immunisation Programme (Mission Indradhanush) to successfully implement its Covid-19 immunisation drive. The rural sector would be dependent entirely on ASHA workers and PHCs for this to happen. As frontline health workers, they were already part of the vaccination drive last month and were administered the first doses.
The ASHA workers will manage the CVC (Covid Vaccination Centre) and PHCs, ensuring that everyone gets vaccinated in their area, mobilising the community and administering the vaccine where required. Some state governments such as Delhi have been training them since December, but the situation is not uniform across the country. Every village has a team of five ASHA workers and along with anganwadi workers, they are going to helm the vaccination drive in the villages and urban slums in the State or Union Territory where they work.
“They also play the dual role of spreading information about the vaccine, and addressing the reservations residents might have about taking the jab,” says Dr ZS Marak, additional director, the Directorate General of Health Services, Delhi.
Now that the spotlight is on ASHA workers, they hope that their problems will be addressed. Many, for instance, are still to be vaccinated. Sarita Gaharwar (32) from Pairaiya Khurd village, Bihar, missed out on her first vaccination shot. “Other ASHA workers got their vaccine dose as the PHC officer had sent them an SMS. The message never reached me,” says Gaharwar. She is also worried about the non-payment of Covid-19 duty remuneration as yet, but adds that irrespective of that she would continue to put in her time (and perhaps money) to serve the community in time of this health crisis. Several state governments are set to deploy them at the Covid-19 vaccination centres under the PM Jan Arogya Yojana.
Long hours, low returns
ASHA workers are women health activists appointed by the government to promote institutional deliveries among pregnant women under the National Health Mission. Over the years, the ASHA workers have become a crucial part of the country’s health infrastructure and the credit for the efficacy of the immunisation programme, particularly its last-mile reach, goes to the armies of these rural women. As volunteers, their work hours remain flexible and many ASHA workers prefer a part-time job as it lets them take care of their domestic responsibilities. However, in reality, their work hours extend way beyond the daily 2-3 hours suggested in the ASHA guidelines.
Says Gaharwar, “I go to the field area designated by me as per my convenience as we are allowed flexible timings. If I have to avoid the sun, I go in the morning and get done by lunch, otherwise I go in the evenings.” She however rues that her job pays way too little compared to the work she ends up doing.
ASHA workers’ job is incentive based, hence their earnings vary from month to month.
Each ASHA health worker serves up to 1,500 people. They often travel long distances on foot, and are the only access to community healthcare that many villages have. “From government health surveys to door-to-door to immunisation programmes, we are the government’s ear to the ground. And yet, our compensation is irregular and the amount paid negligible. The incentives aren’t enough and hardly any facilities are provided for travel despite the fact that our field areas may be farther than what can be considered a walking distance. We pay for this from our pockets,” says Mamata.
In August and September, lakhs of ASHA workers went on a strike along with other trade unions across the country, demanding better working conditions, better pay (at minimum wage) and the perks of a government employee. Treated as volunteers by the state governments as well as the Centre, ASHA workers are thus paid below minimum wage, despite being a crucial part of India’s immunisation drive.
The Covid-19 allowance of ₹1,000 per month has not reached many of them yet, and, a year on, most of them have been performing this work without payment.
Gudiya Devi from Sandasani village in Uttar Pradesh contracted Covid-19 in July last year. While she eventually recovered, work has been difficult ever since, especially covering long distances on foot.
“People don’t always disclose whether they have Covid-19 or not. I must have come in contact with an infected person at work. We didn’t have the option of staying at home like the others. Even when the lockdown was on, deliveries wouldn’t stop even if everything else came to a halt.”
Devi says the wages an ASHA worker gets often do not factor in the extent of their work. “We work more than any other government employee in the village. It isn’t a work that takes just 2-3 hours a day. Why don’t we get compensated like full-time staff then? When will the sarkar see us?” she laments. Devi, though, is grateful to at least have a job.“There are no means of an additional income in these areas, and I am happy to do good work and would prefer if the salary payment was regularised, and given nagad (in cash) instead of the khata (bank account) once in a while.”
There are other worries, too. In Guntur, B Vijaya Lakshmi died soon after she received the first dose of the coronavirus vaccine. Her family thinks it had something to do with the vaccine shot. Says her husband, “She was perfectly healthy. She even went out during the pandemic to quarantine migrant workers and take health surveys. How could she suddenly die? I think the vaccine is to blame.”
India’s health workers had included the ASHA staff in the 30 million frontline workers who got the jab last month. Dr Marak says that whether it is rural slums or villages, ASHA workers are the natural choice for the inoculation drive as they know the population under their area well.
“There is a system in place, and it is successful, as India has its largest inoculation drive under them. They made the natural choice for disbursal of the doses, as the vaccine comes in two parts, and successful implementation involves a follow-up dose. Only the ASHA ecosystem has this level of infrastructure already in place, and they play a crucial role in ensuring the vaccine is successfully administered,” he says.
The shot story
The Covid-19 vaccine in India is voluntary, but it is advisable that as many people as possible to get vaccinated. Targets will be provided to the ASHA workers in each village. The official target is to immunise up to 500 million people till July. Public health professionals worry the additional Covid-19 vaccine targets may strain the current ongoing immunisation programme as well as the mother-child programmes, which are largely dependent on the ASHA workers and ANMs (Auxillary Nursery Midwives) who are in charge of the PHCs.
The Universal Immunisation Programme fell short of its target in 2020, as immunisation doses were skipped because of the pandemic, according to National Health Mission data. India’s immunisation programme includes vaccination for 12 diseases, targeting 56 million people annually, and administering 390 million doses, according to data published by the ministry of health and family welfare. Add to that 400-500 million doses of the Covid-19 vaccine that need to be administered by July.
The Union health ministry also launched the Intensified Mission Indradhanush Initiative 3.0 in February in which the government hopes to cover 90 per cent of the population under its routine vaccination drive (not including Covid-19 vaccination targets). According to the National Family Health Survey Data, vaccine coverage remains around 62 per cent.
Workers such as Sarita Devi are up for the challenge. “We cannot let people down if they are depending on us, whether our salaries come or not. Our fight for recognition will continue,” she says. “Till then, we will continue to immunise the people under our care and be part of the fight to release the country from the grips of the Covid-19 pandemic.”