Left out in the cold

A demonstration on June 22 in Rohtak to demand for ASHAs minimum wages and other benefits enjoyed by government employees.-BY SPECIAL ARRANGEMENT

ASHAs will continue to bear the burden of the government's rural health mission as a new order lists more incentive-based services.

On May 31, a Union Ministry of Health and Family Welfare order listed additional incentivised duties for accredited social health activists, or ASHAs, but was silent on the issue of regularisation of their employment. ASHAs, who bridge the gap between the rural population and the nearest health care outlets under the governments National Rural Health Mission (NRHM) launched in 2005, will now work as family planning counsellors in addition to doing their other duties. They will be paid not for the number of couples they counsel but for the number of couples who agree to adopt family planning methods.

The Ministrys position was that despite the presence of trained family planning personnel, couples were not able to space out and limit pregnancies because of widespread myths and misconceptions and the absence of counselling and information on planning methods. The services of ASHAs, it decided, should be used to counsel newly married couples to have a child only two years after marriage and couples with one child to have a spacing of three years after the birth of the first child. ASHAs were also expected to counsel couples with two children to opt for permanent limiting methods. For every couple whom an ASHA successfully counsels into accepting family planning methods to space out pregnancies, she will get Rs.500. For every couple successfully counselled into accepting permanent limiting methods, she will get Rs.1,000. The scheme is also applicable in urban areas, where the services of AWWs, or anganwadi workers, will be used.

Spacing and family planning are progressive ideas, but to put the onus of this on ASHAs for a pittance seems unfair, especially in a society where the women they counsel may not be in a position to make family planning decisions. Also, ASHAs already work in challenging situations and compete for space with anganwadi workers of the Integrated Child Development Services (ICDS) and auxiliary nurse midwives (ANMs).

The latest government order only strengthens the impression that the government is trying to extract maximum work from ASHAs with minimum compensation. ASHAs, incidentally, are expected to ensure, under the Janani Suraksha Yojana (JSY), that pregnant women opt for institutional deliveries. It is up to them to see that women reach hospitals safely. It is baffling that the government continues to press ahead with its incentive-based programmes for ASHAs instead of regularising their services and those of the AWWs.

According to the notification, ANMs are expected to supervise the work of ASHAs and certify the register of eligible couples prepared by them. They will certify the work done for payment of incentives and maintain a report of the number of eligible couples successfully counselled for the prescribed years of spacing and submit it to the block primary health centre (PHC) in monthly meetings.

On June 22, braving temperatures of over 44oC, ASHAs and midday meal workers in Haryana held a protest in Rohtak, organised by the Centre of Indian Trade Unions, the ASHA Workers Union and the Mid-Day Meal Workers Union, to reiterate old demands for minimum wages, appointment letters, identity cards, social security and other benefits that regular government employees enjoy. There are 15,000 ASHA workers and 30,000 midday meal workers in the State. For the last two years, we have been demanding that they be regularised and given decent wages and other emoluments. They deal with pregnant women, give antenatal and post-natal care, and attend to the nutritional needs of children and women. The government should be paying far more attention to these workers, said Jai Bhagwan, general secretary of the Mid-Day Meal Workers Union.

The story of the NRHM, the United Progressive Alliance governments flagship rural health programme, has been a mixed one. Despite all the hype, crucial health indicators such as the maternal mortality rate and the infant mortality rate show only nominal improvement. The limited success has much to do with how the women health workers are treated under the scheme.

A parliamentary committee has recommended fixed remunerations for the almost nine lakh women health activists in the country. But the government appears reluctant. In November 2011, following a huge protest by ASHAs and their urban counterparts, USHAs, led by the All India Coordination Committee of ASHA Workers, a delegation that met the Health Minister was told that all future responsibilities would be incentive-based.

The eleventh report of the Parliamentary Committee on Empowerment of Women on the working conditions of ASHAs, tabled in the Rajya Sabha and presented to the Lok Sabha on September 7, 2011, made several favourable recommendations. The Health Ministry turned down most of them, though it accepted that ASHAs were crucial for the NRHM. The recommendations ranged from raising the required educational qualification for ASHAs to improving their working conditions and remuneration. The committee recognised that ASHAs were overworked: it said that it was humanly not possible for the ASHA to perform the assigned duties in eight to twelve hours a week. It also made a strong case for better compensation, saying that just performance-based incentives were not enough. It found during its interaction with the workers and mentors that payments were irregular, which it said was exploitative and defeats the very purpose of the scheme. Without exception, ASHAs belonged to poor families, and many of them were widowed or divorced.

Each worker had to cater to some 1,000 people. The work included creating health awareness, counselling women on safe health practices, coordinating with village health and sanitation committees and the gram sabha, escorting pregnant women to health centres and arranging transport, and providing medical care for minor ailments. The committee recommended that ASHAs be freed from roles in Village Health Plans and involvement in the construction of household toilets. It recommended a survey to assess the present workload and incentives. It said that each ASHA should be required to attend to 700 and not 1,000 people. For any additional function, it said, the government should create separate cadre and not overburden ASHAs.

The governments reply to all this was that the Village Health Plan was a useful tool to help the ASHA organise her work. It builds her capacity and empowers her. It said that the National Health Systems Resource Centre (NHSRC) had conducted an evaluation which found that the majority of ASHAs spent three to five hours daily on their work. As for bringing down the number of people in their care, it said that this was a State government prerogative. But it remarked that such a measure might negatively impact the ASHAs earnings.

The committee also suggested that midwives should assist ASHAs during deliveries and that incentives for ASHAs for taking pregnant women to hospital should be structured in a manner that ensured that the women were taken on hospital visits four times at different stages, including at the time of delivery. The ASHA should get Rs.600 for taking the pregnant woman to hospital for delivery and Rs.250 for each of the other visits, including post-natal check-ups. But the Health Ministry held that ASHAs were not trained to conduct deliveries and that the Ministrys policy was to ensure safe deliveries by skilled birth attendants. It also said that an ASHAs incentive for ensuring institutional deliveries would be only Rs.200.

The committee expressed concern at the Ministrys refusal to enhance the honorarium without offering any justification. It also expressed dismay at the Ministrys silence in the action-taken report on issues concerning the shortage, delay and gaps in the allocation of funds. The committee feels that ASHAs play an important role to make the NRHM programme of the country a real success by their referral services, it noted. The committee was also disappointed that the Ministry did not accept its suggestion to institute national ASHA awards to recognise the contribution made by these workers. A few State governments, however, have instituted such awards.

The committee also observed that ASHAs compete with the anganwadi workers and ANMs for incentive-based activities, which negatively impacted the NRHMs objectives. The competing interests not only demotivated the personnel involved but also affected health services. Roles and responsibilities needed to be properly delineated, the committee said. The Ministry countered that there were clear guidelines on this, to which the committee expressed surprise and said that the governments reply was vague and indifferent.

The ASHA has a Herculean task. She is expected to ensure household-level access to health care. She is the bridge between the rural population and health service outlets and has a central role in achieving national health and population policy goals. Unfortunately, she is not treated with the importance she deserves in the health hierarchy, nor is she equipped with the resources she needs to meet the NRHM objectives. The committee, which had interacted with ASHA workers and mentoring groups, noted that drug kits containing basic formulations for common ailments and first-aid tools were kept at sub-centres (SHCs) and not given to the workers.

The committees observations, and not the Ministrys position, are closer to what the ASHAs feel about their situation. They expect us to do everything. We are woken up in the middle of the night when a woman goes into labour. How long it will take for the delivery is something we cannot predict. We put everything at risk, including our position in our families when we go out, but no one understands our state, an ASHA told Frontline. ASHAs say that hospital nurses treated them with contempt, that they are sometimes not allowed to use bathrooms in hospitals, and that they earn nothing when a pregnancy ends in a stillbirth.

Interestingly, the argument given by the government against a fixed remuneration (also recommended earlier by the Mission Steering Group of the NRHM) is that the proposal was not approved by the Ministry of Finance on the grounds that it ran contrary to the approach of the performance-linked remuneration adopted by the department and approved by the Cabinet. The payment, it was further argued, did not justify the concept of an ASHA working as an activist and a volunteer. The parliamentary committee urged the Health Ministry to take up the matter with the Finance Ministry at the earliest. Similar arguments are given when the issue of making ICDS workers and helpers permanent is raised.

The irony is that programmes, laws or policies for women and children continue to be dealt with a deep lack of seriousness and commitment. The ICDS, which is over three decades old, continues to be a scheme and not a full-fledged department. Like the ASHAs, the women workers of the ICDS are poorly paid. Rather than recruit more personnel, the governments approach is to burden the already overworked and underpaid health activists. To expect any dramatic changes in health or reproductive health indicators in such a scenario is unrealistic.