24 The ASHA Workers of Bihar-Saviours of Motherhood

Ms. Kumudini Pati

Introduction

The ASHA (Accredited Social Health Activists) workers, working under the NRHMA (National Rural Health Mission), should be praised and rewarded for their seminal role in improving the social indicators related to rural women and children. As of date there are more than 9 lakh women working as Accredited Social Health Activists in the country and they constitute the backbone of rural healthcare for women and infants. Unfortunately they are not treated at par with other government employees working in the health sector. Their working conditions are dismal and they do not enjoy the status of regular government employees. Of late, however, ASHA workers have begun organising themselves, and have also been participating in agitations in different states for improvement in their working conditions.

The NRHM was established in April 2005, in 18 different states to provide health care services to those regions in India which were the most backward with respect to health care services. The ASHAs are local women trained to act as health educators and promoters in their communities. The Ministry of Health and Family Welfare, Government of India describes them as:

‘…health activists in the community, who will create awareness on health and its social determinants, and mobilize the community towards local health planning and increased utilization and accountability of the existing health services.’

Their tasks include motivating women to give birth in hospitals, bringing children to immunization clinics, encouraging family planning (e.g., surgical sterilization), treating basic illness and injury with first aid, keeping demographica records, and improving village sanitation. ASHAs are also meant to serve as a key communication mechanism between the healthcare system and rural populations.

As of now, the ASHA workers are only given performance-based incentives since they are regarded as ‘honorary volunteers’. In August 2014, replying to a question during the Question Hour in the Rajya Sabha, the then Union Minister for Health and Family welfare, Dr. Harsh Vardhan had replied, ”there is no proposal to give them (ASHA Workers) benefits like Government employees.”1 Dr- Harsh Vardhan had also made a startling statement that ASHA workers were getting an honorarium of only Rs. 800 to Rs.3000 in the different States of India. Putting this in perspective one can see that an agricultural labourer in Haryana may earn Rs. 400 per day and an ASHA worker four times less! Not only this, there are several financial irregularities in the NRHM, which directly affect the ASHA workers. When the CBI inquired into the NRHM scam in Uttar Pradesh, after the Allahabad High Court intervened2, it came to be known that the funds which had been allocated for these health workers under the ‘safe motherhood programme’ or Janani Suraksha Yojanab had actually never reached them and had been siphoned off by the corrupt CMOs and medical officers working at the lower levels. Subsequently, under the Mayawati regime, the CBI had only filed a preliminary report and the affected ASHA workers could never get any compensation for the loss suffered by them. While the ASHA workers are struggling for the status of permanent government employees, in the last fiscal year, the Government drastically slashed the allocation already made to the Union Health Ministry by 10 percent, which comes to around Rs. 2400 crore. The result was that the agenda of expansion of the NRHM was badly hit, because of which further recruitment of ASHA workers was stalled; the shortfall in the employees’ strength falling in the range of 20-30 percent.(Estimate of the National Commission for Macroeconomics and HealthC, NCMH) The NRHM annual review reports came up with even higher percentages, i.e. around 40 percent for different States. We are yet to see what will be the fate of the election promise of ‘Health for All’.

The Tasks of the ASHA workers

Besides giving prenatalc and postnatald care to mothers and taking them to the Health Centres for institutional Deliveries as well as providing health care to the infants of these mothers, there are a number of additional tasks that are to be performed by the ASHA workers working under the NRHM. This additional work does not fetch them any additional income. In a sense, this is some kind of forced or ‘involuntary’ work. Some of these tasks are:

1. Epidemic Control

ASHA workers have to undertake H1N1/Bird Flu/AIDS awareness campaigns, as well as relief work in affected areas; for this they are not entitled to extra remuneration. In States like U.P. and Gujarat they have had to conduct surveys to identify people suffering from Swine Flu.

2. Family Planning

ASHA workers have to campaign for family planning methods and even distribute contraceptives in rural areas.

4. Administering ORS

ASHA Workers are made to do house-to-house surveys to administer ORS (Oral Rehydration Solution) to children suffering from diarrhoea and a performance-based incentive of RS.1 per child is given.

5. Work During Natural Disasters

In States like Uttarakhand and Jammu and Kashmir, the ASHA workers were having to do disaster relief work under the guidance of NDRFD (Natural Disaster Response Force) and the Indian Army. They were given no extra incentive for this.

Overworked and Underpaid

The ASHA workers have to rush expectant mothers to nearby hospitals at short notice. They have to spend from their own purse for transportation and the honorarium is sent to their bank accounts after considerable delays. For antenatale check-ups of expectant mothers they receive a petty honorarium of just Rs. 300, whereas they have to often make several visits in the later stages, or if there are pregnancy-related complications.

These para-workers are paid a pittance in terms of honorarium, i.e. just Rs.1000, on an average. For this they have to have a Class 8 certificate and have to undergo special training, during which period they are not paid anything. They are given cheap mobile phones and receive orders through SMS; they are kept track of all the time. After a lot of protest, the Mamata Banerjee Government of West Bengal increased the monthly honorarium from Rs.1,000 to Rs.1300. The Left Front constituents have started organising the ASHA workers in different states and have demanded an honorarium of at least Rs. 10,000 per month although interestingly they had never increased it during their own rule in W.B. and Kerala; nor are they planning an increase in the State of Tripura where they are in power.

The NRHM Scenario in Bihar

In a survey conducted in Bihar among 2 lakh rural households, it was found that only 8.39 % people had some kind of toilet in their homes. A large number of families did not have access to pure drinking water. There were potholes all over, where dirty water accumulated, and caused spread of disease. Defecation in the open, excessive use of asbestos for construction, along with contamination due to the use of pesticides and insecticides (arsenic contaminationf) is causing health hazards. AIDS is spreading fast in North East Bihar, as migrating labourers going to Bombay, Gujarat and other Metro cities come back to their home towns during the agricultural season. On the other hand, lack of sanitation and unhealthy conditions have led to the spread of Dengueg. However, the NRHM can only try to develop health infrastructure and services to the extent that the budget allocation permits. But considering the enormity of the task and its ever-growing character, it is the ASHA worker who hears the brunt of any laxity in developing health infrastructure and conducting health awareness campaigns. For example, in the State the rate of population growth has been above the national average-it is 25.07 against the national average of 17.64. The Child Mortality Rate in Bihar is 42 (National average 40) and Maternal Mortality Rate is 219 (National Average 178) are also higher than the national average. Women’s Literacy stands at a dismal 53.33% as against the National Average of 65.46%. The Crude Birth Rate is 27.6 as against the National Average of 21.4.h These conditions have increased the pressure of work on the ASHA workers of Bihar. The health infrastructure has improved in the past few years in terms of the expansion of Primary Health Centres and Sub-Centres; yet there is a shortfall of 1220 PHCs and 8837 Sub-Centresi and many remain unmanned or poorly manned by competent doctors and health workers. For example 8822 posts for health workers lie vacant and there is a dearth of female doctors and child specialists. ASHA workers in the state number more than 71,350 and most of them come from families with low income and are from socially unprivileged communities. Their formal education is also only up to class 8 and most of them have joined the NRHM to earn some extra money, since their families were not in a position to educate them further. Several may be married and divorced or widowed; since unmarried girls are not given preference. The overworked ASHA worker in Bihar has to do multi-tasking. It is for this reason that in Bihar only 26% pregnant women are able to avail the 3 standard check-ups needed. Only about 50% deliveries are institutional deliveries. The immunization rate also stands at 40-45% in the entire Hindi-speaking belt.

Crucial Role of the ASHA workers

Working on a petty honorarium, the ASHA workers have been sacrificing their precious time and energy for building a healthy Bihar. Besides taking expecting mothers for institutional deliveries, providing pre-natal and post-natal care, distributing medicines in association with the Anganwadis, conducting the Rainbow immunisationj programme, conducting pulse polio programmes, campaigning for family planning, encouraging village people to participate in sanitation drives, conducting awareness about the importance of dry toilets and fresh potable water, creating awareness regarding nutrition for pregnant and lactating mothers, breast feeding and child care, proper use of contraceptives and proper personal hygiene, etc. have to be managed by the ASHA workers. The work done by the ASHA workers demands a 24×7 work schedule. Many times they have to go in the darkness of night to transport pregnant women for deliveries to the primary health centre. This is extremely risky because the woman might deliver on the way and there would be no facility. Often the ASHA worker has to awaken the doctors and nurses at the PHC, clean the place and even make arrangements for illumination if electricity is unavailable. Sometimes, if there is a complication which cannot be managed by the PHC staff, the ASHA worker has to take the woman to a nearby hospital and wait there till she is admitted and the child delivered.

Attitude towards ASHA Workers

An underdeveloped semi-feudal society considers the ASHA worker some kind of ‘low caste’ woman who is given the status of ‘Chamarin’ ie a dalit. She is often humiliated by doctors and permanent nursing staff if she fails to bring the patients in time due to difficulty in transportation, which is actually not her fault. Lack of infrastructural facilities like proper roads, local transport etc. are still major issues in rural Bihar. The ASHA workers are supposed to be given a meagre sum of Rs. 600 for each institutional delivery, but according to first-hand accounts, they get only Rs. 300 and the rest is shared by the staff in the PCHs. It is also strange that Rs 150 per child as honorarium is given to an Asha worker only under the condition that she achieves total 100% immunisation in the village; in case it drops to 50% she is paid nothing, whereas for a pulse polio programme she is given a paltry sum of Rs. 75 for a whole day of work. For an individual completing family planning, Rs. 150 is given. Several ASHA workers have complained of sexual harassment by doctors, male employees at the PHCs and hospitals as well as male relatives of the expectant mother.

Work burdens at home and outside

ASHA workers actually don’t have any stipulated hours of work. They may have to go to work in the dead of night or wee hours of the morning. They may have to spend 24 hours a day during intensive campaigns and programmes. So the task of managing the home and working for NRHM becomes almost impossible. An ASHA worker complained that all her family members including husband remain unhappy with her because she is unable to fulfil their expectations at home, whereas her contribution to the family income is meagre. Even her grown-up daughter said one day that other mothers were much better because they at least cared for the children. Some workers said they became so tired after reaching home that it became extremely difficult to discharge household responsibilities; hence there would always be pressure to quit such a low-paid job. Moreover the ASHA workers’ own health is jeopardised.

Backbone of Rural Health yet Discriminated

The UNICEF and many other agencies have recognised the enormous contribution of the ASHA workers. They form the backbone of rural healthcare and have made immense sacrifices. They are called the ‘ASHA Didis’ in Bihar and rural womenfolk are totally dependent on them in a State which is most backward in terms of social indicators. Although they are appointed on a contract basis and acquire skills during their term of work, they are not being made accountable to the employer i.e. NRHM, rather they are forced to report to corrupt health officials. This is one reason for their exploitation. Many ASHA workers feel that they must be freed from the clutches of the corrupt health bureaucracy so that they can work in an environment which is autonomous and free from corruption; according to them this is one reason why their image is often tarnished.

Organising ASHA Workers-an Experience

Organising the ASHA workers first started with some NGO members who were also working in the NRHM. Some health workers took an initiative in organising them in certain districts of Bihar. The traditional Trade Union centres and Employees’ Organisations have only recently begun thinking in this direction, seeing the potential of these health workers in developing massive contacts among common rural womenfolk. But it is unfortunate that so for as organisation, education and assertion is concerned, the efforts of these Associations at the grass root level are far from satisfactory. Along with the Bihar State Non-gazetted Employees’ Federation and All India Central Council of Trade Unions, the All India Progressive Women’s Association began organising the ASHA workers in 2007. Instead of raising issues from above, they began organizing these women at the grass root level and training them. In more than a dozen districts, block-level workshops were organised to understand their problems and discuss as well as resolve them through struggles. District-level conventions were held. Some of the issues that were on top priority were: identity of the ASHA worker as a health worker, a regular wage of Rs. 10,000 per month, maintaining her dignity and better treatment at the hands of officials.

They also demanded ID cards so as to be able to admit women into the PHCs and Hospitals without having to answer myriad questions. This demand became popular in the entire state and ID cards have now been issued all over the state. The ASHA workers had never been allowed to use nurses’ toilets since the keys were always in the possession of the nurses or other employees. Now they are allowed access in several PHCs.

Organization has brought a qualitative change in the consciousness of these workers. So we see that the personal complaints regarding low honorariums has given way to district level meetings and district conferences. Also, ASHA workers are helping to change the work environment by collectively protesting against cases of sexual harassment. This has instilled greater confidence and a sense of unity among them.

Struggle for recognition

The ASHA workers of Bihar began to hold village-level meetings first to discuss their problems and form a consensus on issues. Then they met ASHA workers from other villages and decided to organize at the block level. Pamphlets with 11 demands formed their Charter of Demands, and these were distributed in different blocks to raise awareness. The Block-level meets converged into District Conventions and then it was unanimously decided that the process should culminate in some action programme at the State level so that the ASHA workers’ Association could have a new identity and serve as a model for other States. Many ASHA workers with different ideological moorings began to join the ASHA Workers’ Organisation led by the All India Progressive Women’s Association. They chanted “Pagar Nahin to Kaam Nahin” (No Wages, No Work) and decided to strike work on one day as a token of protest on Pulse Polio Day.” We have made the Pulse Polio Programme of the Government a success and also achieved 100% immunisation in our areas; we have brought down the Maternal Mortality and Infant Mortality rates. Why are we being denied our rights? “ said the ASHA leaders and workers.

Not to be Cowed down, on the night of 20 June, 2015, the ASHA workers began gathering at the Primary Health Centres and Civil Surgeons’ Offices. It was a sight to see so many women health workers thronging for their strike action the next day. On 21st the Pulse Polio Programme and other health services were brought to a total standstill. Seeing the assertion of these ASHA workers, the District Administration, instead of giving them a patient hearing, began to threaten them saying their appointments would be cancelled and new recruits would be taken in. False cases of disruption and vandalism were filed against them in the local thanas, despite the fact that the ASHA workers had only been chanting slogans and asking the Administration to forward their Memorandum with 11 demands to the Central Government. The Bihar Health Department began to collect the names of the striking workers instead, and preparing lists of workers to be retrenched. Letters of retrenchment started being prepared. But instead of retreating or getting divided due to victimisation, the workers’ unity became stronger in favour of the one-day strike. Many Civil Surgeons began to send letters to the Government to sort out the matter as soon as possible so that a major crisis could be averted. The pressure worked and the same administration who had said one month back that they had nothing to do with the NRHM, realised that they would have to call the ASHAs for talks and discuss their problems. On 24th July the Bihar ASHA Workers’ Association along with the Bihar State Employees’ Association and All India Central Council of Trade Unions were invited by the Chief Secretary of the Health Department. A seven-member Committee to fix a proper monthly wage for the ASHA workers was set up. Among the other demands conceded were-cycles for all ASHA workers, rest rooms with toilets at the PHCs, disbursement of pending incentives, raising the incentives, which had remained stagnant for the past 10 years, setting up of Committees against Sexual Harassment, EPF facility, Maternity Leave etc. were some of the demands which the Health Secretary conceded. All retrenchments were withdrawn by the Government and the 11-point Demand Charter was sent to the Central Government.

The Indian Labour Conference

Another important issue that the ASHA workers have now started raising is that the honorarium being given to them is not commensurate with their skill and labour. In fact less skilled and less risky 8-hour jobs are being paid much more by employers. They have also begun to raise the issue of coverage of ASHA workers under the Aam Aadmi Bima Yojana or Rashtriya Swasthya Bima Yojana. They have also demanded that their work be clearly defined, so that they are not at the beck-and-call of Officials.

The 45th session of the Indian Labour Conference (ILC) discussed the status of ASHAs and proposed to the government that they be treated as employees of the government and not voluntary workers4. This recommendation of the 45th ILC is yet to be accepted. The Standing Labour Committee relented from including the issues of ASHA workers and other para-workers in the 45th ILC in 2013 and the sad reality was that the unions let go of the opportunity without a vigorous discussion or forcing the ILC to adopt strong resolutions. The unions should work hard to get even the diluted proposals implemented and try to get stronger resolutions passed in future bipartite occasions as the employer here is the government. Meanwhile, the Centre rejected the ILC recommendation of paying minimum wage to ASHA Workers5 Many demands are still pending, for example:

The ASHAs should also be entitled for six months maternity leave and other maternity benefits.

There should be separate restrooms with privacy and adequate security for ASHA workers in all medical establishments to which they take women for delivery and treatment at all odd hours.

There should be improved transportation facilities and interest-free loans for two-wheelers.

Effective mechanism to curb sexual harassment not only at the workplace defined narrowly as the clinical centre but also while on work and visiting villages too.

Stringent punishment should be meted out under special provisions to be incorporated in relevant laws.

In many States, the dues of ASHA workers are cleared after 3 or 4 months and the government should put in place a system wherein the dues can be cleared the same month.

Irrespective of the performance-based incentives/allowances, some minimum subsistence allowance should be entitled to them.

Health officials and even ANMs taking unofficial cuts from the allowances of ASHA workers should be made a penal offence with stringent punishment and all remuneration of the ASHA workers should be directly credited to their bank accounts.

These are some of the demands raised in different states by Left-led Trade Unions, but so far no All-India Association of ASHA workers has been formed, which is the need of the hour.

Terms and References

A. NRHM: nrhm.gov.in

B. Safe Motherhood Programme: https://www.rbfhealth.org/…/india-janani-suraksha-yojana-safe–motherhood

C. NCMH:www.ncbi.nlm.nih.gov › NCBI › Literature › PubMed Central (PMC)

D. NDRF:https://en.wikipedia.org/wiki/National_Disaster_Response_Force

E. https://en.wikipedia.org/wiki/Arsenic_contamination_ of_groundwater

F. www.webmd.com/a-to-z-guides/dengue-fever-reference

1. Source: http://www.business-standard.com/article/pti-stories/no-plan-to-give-govt-employees–benefit-to-ashas-vardhan-114081200303_1.html
2.   http://www.hindustantimes.com/india-news/nrhm-scam-probe-is-now-cbi-s-biggest-investigation/article1-1248300.aspx
3. http://nrhm.gov.in/nrhm-in-state/state-wise-information/bihar.html
4. http://articles.economictimes.indiatimes.com/2013-05-18/news/39354614_1_monthly-pension-pension-scheme-pension-benefit
5. http://nrhm.gov.in/nrhm-in-state/state-wise-information/bihar.html
6. http://www.deccanherald.com/content/384231/centre-rejects-ilc-recommendations-minimum.html.