‘I became an ASHA to support my family. But now, I would rather quit’Written By News Root | Published on Updated: Sep 15, 2022, 14:10 IST | 1663231208605They accompany pregnant women for health check-ups, assist in institutional deliveries, and constantly monitor the health condition of new mothers and babies. But despite their valuable contributions, ASHAs are woefully underpaidASHA worker Sunita Devi (on the extreme left) during her visit to Sonbarsa (Photo Sobha Yadav)
Sitamarhi, Bihar: Renu Gupta hardly earns Rs 4,000 a month. Nevertheless, her job involves visiting more than 50 houses a day, mostly on foot. She is an Accredited Social Health Activist (ASHA) in Sursand village of Sonbarsa block in Bihar’s Sitamarhi district. “Up until a few years ago, my only source of income was the cash incentive offered for assistance during institutional deliveries. Thankfully, the government started giving us a monthly honorariums of Rs 1,500 since 2019, but it is not enough to meet our daily needs,” Gupta tells 101Reporters.
Convincing pregnant women to opt for delivery in a hospital is an uphill task. Yet, ASHAs are not paid for months together. The same is the case with postpartum benefits for mothers, which further discourage many from opting for institutional deliveries. According to Sonbarsa's Block Development Officer Kunal Kumar, the pay is occasionally delayed due to inconsistencies concerning COVID-19 and the requirement that we confirm a child's birth with a hospital in order to qualify for incentives.
ASHAs also have to work towards achieving immunisation and other health targets, leaving the women overburdened. “We were absolutely worn out during the second wave of COVID-19, especially where pregnant women had to be cared for. Most of the time, we were working without Personal Protective Equipment (PPE) kits. We had to compel people to get vaccinated, even as we feared for our own safety, and that of our families,” Gupta recounts.
Sunita Devi of Bajpatti village in Sonbarsa has a similar story to tell. “I have to conduct regular surveys. If I come across pregnant women, I register them, prepare their medical cards, and arrange for additional testing. During the course of their pregnancy, I must call on them four times to arrange for tests, before accompanying them to a government hospital for delivery.” “After delivery, for around one-and-a-half months, the mother's health, baby's weight and dietary needs should be monitored. Subsequently, the child has to receive all the necessary vaccinations,” she details.
Devi has been working as an ASHA since 2013, but her honorariums and incentives have often failed to arrive in time following the pandemic. Not just that, she ends up paying the travel expenses of pregnant mothers from her own pocket. “I became an ASHA in the hope of supporting my family. But now, I would rather quit,” she says.
Beacons of hope
In recent years, the maternal mortality rate in Bihar has come down to 130 fatalities per 100,000 live births, though it has remained higher than the country's average of 103 fatalities in 2017-2019. Institutional deliveries in Sitamarhi district stand at a meagre 37%, which is far less than Bihar's average of 76.2%. Home deliveries conducted by skilled health personnel form only 9.6%, proving how crucial the role of ASHAs is in Sitamarhi.
Sushmita Singh, a pregnant mother recounts the service given by an ASHA didi in the last five months of her pregnancy. She helped Singh with diet, medicines and visits to the government facility. “She convinced my husband about institutional delivery and the benefits the government provides for both prepartum and postpartum needs. Thanks to her, my baby and I are healthy. My family will always be thankful to her.”
Monika Mishra, now in the seventh month of her pregnancy, acknowledges her debt to ASHA Aamna Karimi. "Since I knew her, I put all my trust in her. She accompanied me for my check-ups more than thrice, and took me to clinics for the necessary tests. Every time I suffer from pain or illness, we call her and get her opinion, rather than taking any over-the-counter medicine.”
Though ASHAs provide both prenatal and postnatal health care, their work does not stop there. They dispense oral rehydration solution, condoms, iron and folic acid tablets, and disposable delivery kits to rural communities. Additionally, they deal with cases of diarrhoea and fevers. After being trained on tuberculosis treatment for 23 days, they presently administer Directly Observed Therapy Shortcourse (TB-DOTS) as well.
Chinks in the armour
Promoting institutional delivery under the National Health Mission’s Janani Suraksha Yojana (JSY) is the foremost duty of every ASHA. As a demand-side financing programme, the JSY pays them for every institutional delivery they assist in. On its part, the Bihar government pays every ASHA Rs 600 for every institutional delivery, while the postpartum mother is entitled to Rs 700. The state also gives ASHAs Rs 1,000 per month. Bihar has a total of 92,500 ASHAs, but they end up covering more areas than they are supposed to, mainly due to the shortage of health workers. The pandemic has further delayed the selection and appointment of new ASHAs.
Besides overwork and underpayment, ASHAs complain about other professional lapses, too. “Although we facilitate immunisation, we are not considered health workers and receive no institutional support from the government. We contribute towards maternal health education and provide basic medical care, but the training provided is sub-standard and does not help us in doing our job,” Aamna Karimi told 101Reporters.
However, Kunal Kumar confirms that an additional four-day training has been scheduled for ASHAs next month, and “they shall be provided with the necessary equipment.” Regarding the shortage of ASHAs, Kumar says appointments will be made at the earliest. “Additionally, the Bihar government has decided to provide ASHA workers with an additional Rs 500 annually for the purchase of uniform, against the earlier Rs 1,000,” he informs.
(The author is a freelance journalist and a member of 101Reporters, a pan-India network of grassroots reporters.)