Health warriors’ woes

The COVID crisis has increased the work pressure on National Health Mission staff, but there is no effort to make their remuneration commensurate with their efforts.

Accredited Social Health Activist (ASHA) workers conducting a door-to-door survey on the COVID situation, in New Delhi on July 2.

In the early phase of the COVID-19 outbreak, Prime Minister Narendra Modi exhorted the nation to bang utensils and clap as a mark of appreciation for health workers fighting the pandemic. Perhaps that made National Health Mission employees feel that their work was being recognised at last. When one Chief Minister declared that he would double the salaries of NHM workers in his State, Rihan Raza, all-India president of the NHM employees’ union, declined the offer politely. The health workers were after all doing their duty, he reasoned. Today, he rues his decision.

Only a tiny percentage of NHM staff are permanent employees. The mission is run on the principle of incentives and conditionalities, which militates against the goal of good health outcomes and is demotivating for its workforce. A Health Ministry document links the allocation of NHM funds to States with performance-based conditionalities. The Result Based Financing Approach, basically a carrot-and-stick approach, is a brainchild of the NITI Aayog.

Frontline spoke to several NHM workers and their representatives in Haryana and Rajasthan. Of the nearly10.5 lakh NHM workers in the country, nine lakhs are Accredited Social Health Activists (ASHAs). In Haryana alone there are around 14,000 NHM workers, who are radiologists, pharmacists, accountants, data entry operators, lab technicians, ambulance drivers, staff nurses, auxiliary nurse midwives (ANMs), AYUSH doctors and paramedics. There are also 20,000 ASHAs.

ASHA workers receive a paltry fixed amount and an incentive-based honorarium, which is bad enough. The rest of the NHM staff are on a renewable contract with no social security or additional benefits. The contract was earlier for only three months. Following protests by NHM staff, the Haryana government agreed to extend it to nine months. The terms of the new contract, a copy of which is available with Frontline , came into effect in March 2020. It says services can be “automatically terminated” on expiry of the contract, without any notice or any liability to pay any remuneration or compensation. The NHM staff have no “right or claim or preference either for regular appointment in the State government or for regular appointment in any government job or for regularisation or for extension of the period of contract.” The contract employee is required to undertake to not make “any claim at any point of time”, not even in the future. But though employees signing the contract “shall not claim any right to be treated as a government servant or be absorbed in government service at any future point of time”, they are expected to function with “professionalism, utmost care, skill, honesty, good faith and integrity as well as high moral ethical standards”.

The appointing authority retains the right to terminate their services at any time during the tenure of the contract on grounds of “insubordination, professional misconduct, unsatisfactory or poor performance, irregularities and impropriety committed of administrative or financial nature, unsafe practices, inefficiency, insensitivity, false reporting of information and fabrication of data in maintained records”.The contract can also be terminated on other grounds such as non-availability of funds for the project,rationalisation of activities depending on the government’s needs, and discontinuation of the project by the Central government. The contract says that as health services are essential services, provisions of the Essential Services Maintenance Act apply to NHM workers, who cannot therefore strike work or protest.

NHM workers are expected to have a phone by which they can be reached “at all times”; they are expected to be able to serve at any place within the State in the public interest. They must stay at their place of work (“headquarters” in NHM parlance) and cannot travel out without permission.

The contract says NHM employees cannot contest elections for public offices or take up any other activity or work. These are restrictions that apply to government employees, a status that NHM employees do not enjoy.

The government has the right to amend the job description and the “minimum performance benchmark”to suit its requirements. Haryana requires NHM employees to secure an 80 per cent performance grade to be eligible for contract renewal.

In the front line

ASHAs and other NHM workers are in daily and direct contact with the community; they are responsible for collecting information on all health indicators and helping the community to access treatment. They are the first to come in contact with suspected COVID-19 patients and help them in getting screened and accessing treatment; they are also responsible for maintaining records of those patients and their contacts.

The pressure on this workforce increased exponentially in the past few months. Yet, regularisation of their services was not on anyone’s agenda. No surprise, then, that NHM workers in various parts of the country have been protesting against their pitiable working and living conditions. (They have also been performing their duties.) In June, 1,800 employees in Nagaland organised protests demanding pay parity with permanent Health Department employees. There were protests in Haryana and Rajasthan also.Raza, who is also the president of the Haryana unit of the NHM employees’ union, told Frontline that the conditions of the contract in Haryana were demoralising. “We are called corona warriors but when it comes to treating us like government employees, the government backs out. We need job security if we are to effectively fight the coronavirus,” he said. He recalled that when blood banks ran short of blood for transfusions, NHM workers got together and donated 2,000 units and declared they would be happy to donate again if the need arose.

Speaking of the pressure on ASHAs, Raza said: “The ASHAs are the point of contact for the community. All health indicators have to be monitored by them. Yet they do not even get minimum wages. Our work begins after all the material is collected by them. We collate, keep accounts, make payments. A doctor cannot deliver a baby without the help of an NHM worker.”

Though primary health care centres (PHCs) are able to wind up work after a few hours every day, the NHM worker must be on call. The pandemic has not only increased the pressure on NHM staff but endangered those who work in close contact with the community. Raza pointed out that while ASHA workers were expected to do contact tracing and help those with symptoms get tested, they were not given adequate protective gear. They are given simple cloth masks instead of triple-layer ones and a cake of soap instead of alcohol-based sanitisers. Worse, if any of these workers are quarantined after testing positive, their wages are deducted.

Anil Kumar Racheta, secretary of the Sikar district NHM employees’ union in Rajasthan, had a similar grouse: increased pressure but inadequate compensation.

When the NHM was launched in 2006 with funding assistance from the World Health Organisation (WHO), by the Central and State governments, the gap between emoluments for medical and the non-medical cadre was not very wide. But after 2008, while the salaries of the permanent employees went up following the implementation of the Sixth Pay Commission, contract workers remained out in the cold. “We are given only a 5 per cent annual increment, which is around Rs.500. When the project began, MBBS doctors under the NHM earned slightly more than we did. Today they earn in lakhs and we are where we were,” Racheta told Frontline . While many of the NHM’s medical staff were made permanent, the entire management cadre was on one-year contracts, he said.

There are pay disparities between the State-, district-and block-level cadre. While the district- and State-level management cadre’s salaries went up after the Sixth Pay Commission, there was no commensurate increase in the salaries of block-level NHM staff. Anil Kumar Racheta, who is an accountant with the NHM, was paid Rs.8.000 a month in 2008; 10 years later, his monthly pay was Rs.16,000.

There are close to 3,000 NHM employees in Rajasthan. The government insists on their presence in the villages where they serve. Earlier, they took buses to the villages, but now there is no public transport. Racheta said: “They expect us to be there when sampling and testing is done. We don’t get any house rent allowance. How can we stay in the villages? Earlier it was cheaper as we used to go by bus, but now we take our motorbikes. There is no public transport because of COVID-19. We are given no extra allowance for the petrol costs we incur.” Accountants like him make payments to ASHAs and other employees. They make entries and file reports on a day-to-day basis. So there is no option but to go to the villages.

Sunita Rani, general secretary of the ASHA workers’ union in Haryana, told Frontline that the work done by ASHAs and other NHM staff showed clear results on the ground. Within five years of the NHM’s launch, infant mortality and maternal mortality rates had improved. Nearly all deliveries now were institutional, she said. The limitations in the system were in the infrastructure and not in the performance of NHM staff, she said. Explaining how ASHAs were made to address crises that were not of their making, she recalled how they were asked to address the problem of anaemia when it was found that 71 per cent of the women and children in Haryana were anaemic.

An ASHA herself, she said ASHAs were over-burdened. At the time of self-appraisal, they were supposed to fill as many as 45 columns, which showed the amount of work they were entrusted with. Distributing iron tablets, mapping immunisation, mapping the number of children, getting pregnant women to undergo pre-natal and post-natal check-ups, ensuring institutional deliveries, and keeping a watch on non-communicable diseases were some of their routine activities.

The pandemic has made things harder. “We hardly received any training on how to handle people infected with COVID-19. It took us a month to convey to people what the virus was all about. In April, they told us to visit homes and give reports. We encountered a lot of hostility. ASHAs were attacked, abused and even threatened during the lockdown, even by the police. All the clapping and banging of utensils did not help our situation,” she said.

One of their tasks was to identify homes with infected residents. When they tried to do this, village residents threatened them.

Sunita Rani also said that the lockdown and job losses took a toll on women, many of whom suffered domestic violence and forced pregnancies. The reproductive health of women also suffered in this period. Children missed out on important vaccinations because of lockdown restrictions, and pregnant women had to go without routine check-ups. “We were at risk too. If we fell ill, there was no empanelled hospital where we could claim treatment. We implement government schemes but are not government employees,” she said.

In one village in Sonipat, among the worst COVID-affected districts in Haryana, an ASHA put up a quarantine notice on a home. The home owner, who was related to the village sarpanch, threatened to kill her. In Gohana, also in Sonipat, an ASHA and her daughter were beaten up for the same reason. Attacks on ASHAs were also reported from Gurgaon, Hisar, Faridabad and Panchkula. In Yamunanagar, an ASHA who was on duty in the city asked her teenaged son to pick her up on his motorbike as there was no transport. The police pulled up the boy for not wearing a helmet and fined him Rs.25,000. “She is a widow. Where would she get the money to pay the challan? This is how corona warriors are being treated,” said Sunita Rani.

The allocation for the NHM in the 2020-21 Union Budget was reduced by Rs.390 crore. The budget for capital outlays under the NHM meant for strengthening rural health infrastructure went down considerably. There has been no commitment from the Central government to either regularise all NHM staff or increase their emoluments significantly. This indifferent approach is bound to take a toll on the poorer sections, who depend majorly on public sector health care, and on the NHM itself in the long run.