Front line ASHA workers are at the bottom of the electoral discourse

Patti Kalyana village in Haryana’s Panipat district is known for its wrestlers, kabaddi players, volleyball enthusiasts and gallantry award-winning soldiers. It seldom figures in conversations on public policy.

But a long chat with Suman, a feisty frontline health worker in this village of 10,000-odd people, may open one’s eyes to some grassroots issues that are key to the future of India’s healthcare system — no matter who forms the next government.

To reach Suman’s home, we walk down a sleepy village road, past a riotously coloured signboard for a public school, a bael tree laden with fruit, and stagnant pools of dirty water.

Suman is an accredited social health activist (ASHA), one of the 9,00,000-odd women who form the backbone of India’s primary healthcare system. Currently, she is president of the ASHA workers’ union in Panipat.

“I was the first woman in this village to knock off the ghunghat (veil). I married for love. There was no dowry. I had finished class X when I got married. My daughter and I did our class XII exams together,” says Suman, as she adjusts her bright red-and-blue dupatta over her shoulder, and we settle down for a cup of tea in her living room.

We chortle about the battles of Panipat that every Indian school-going child is familiar with and quickly move to the modern-day battles that frontline health workers such as Suman are waging for recognition and fair remuneration — issues mostly neglected in the public discourse about health reforms in this country and seldom raised in electoral campaigns in Karnal, Suman’s constituency.

The Narendra Modi government pitched Ayushman Bharat as part of its big idea on healthcare. Most Indians know of the Modi government’s much-publicised healthcare model through Pradhan Mantri Jan Arogya Yojana (PMJAY), a health insurance initiative launched last September. It seeks to provide around 500 million poor and vulnerable Indians with an annual cover of ₹5,00,000 for secondary- and tertiary-care hospitalisation. The other critical but less-promoted component of Ayushman Bharat is the plan to set up 1.5 lakh health and wellness centres (HWC) to provide comprehensive primary healthcare. The deadline is 2022.

The Bharatiya Janata Party underlines Ayushman Bharat in its manifesto, while the Congress promises to expand the ASHA programme and appoint a second ASHA in all villages with a population exceeding 2,500. But there is still little talk about the plight of overworked and underpaid frontline health workers.

In 2005, Suman was among the first ASHA batch hired as part of the National Rural Health Mission. The first cheque she got for a whole year’s work was for ₹550.

Her earnings have gone up, but her workload has increased many times over. There are nearly 40 tasks that she must carry out. These include motivating women to give birth in hospitals, bringing children to immunisation clinics and encouraging family planning.

Despite all the promises that have been made, the health workers still do not get a fixed salary. “Every tiny hike has come after a struggle,” Suman says.

In 2018, a strike by the workers in many states grabbed headlines. As Karnal waits for the election results like the rest of India, Suman says anxiety among frontline healthcare workers is palpable. They are demanding regularisation and recognition as ‘workers’ but have so far met with little success.

Last September, on the cusp of Assembly elections in five states, Prime Minister Modi had announced an increase in remuneration for ASHA and anganwadi workers. “He talked about the dedication of the three ‘A’s – ASHA, ANM (auxiliary nurse and midwife) and anganwadi workers. He announced the doubling of routine incentives given by the Centre to ASHA workers. But we are yet to get the promised money. Last month, we were told that we would get it from this month. But what about arrears? Our struggle has been for a fixed amount of money which is proportionate to the amount of work we do and recognition as workers,” Suman says.

The Modi government says health and wellness centres will deliver an expanded range of services by a primary healthcare team made up of multi-purpose workers and ASHAs and led by a mid-level health provider. But the health activists want clarity. “Where does the ASHA worker fit into the new framework and what is the expectation from them? There is an urgent need for a clear policy direction,” says public health expert Anant Bhan.

Patna doctor Pratyush Kumar, who chairs the South Asia rural health group of The World Organization of Family Doctors, adds: “Frontline workers work in a fragmented way and the focus is on multiple, vertical, disease-specific programmes. There should be an effective primary healthcare team.”

It is not that nothing has happened in the last five years, Suman points out. “There is a biometric attendance system now at the PHCs and this has helped reduce absenteeism among doctors. But there are severe challenges on the ground. For example, we used to have deliveries at the Patti Kalyana PHC four years ago. No longer. Now women have to travel 5-6 km to the community health centre at Samalkha,” she says.

Where does this leave India’s health reforms story? “Frontline workers get a measly honorarium which is not at all commensurate with their workload. Their remuneration is a low priority for the health establishment,” says Sulakshana Nandi, national joint convener of Jan Swasthya Abhiyan (People’s Health Movement). “The health workers remain exploited,” she adds.

Patralekha Chatterjee is an independent journalist based in Delhi

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