Who do you think were the most sought-after agents of healthcare at the community level in Kerala during the pandemic days? Make no mistake. They are the health volunteers called 'Asha Workers'. Asha workers have been working amongst us for more than a decade. But no one had really acknowledged their worth, until Covid-19 broke out shattering the calm across the globe. The first stage of Covid was the most painful. When patients were isolated from their near and dear ones, it was Asha workers who stepped in and took care of them.
There were days when Kerala eagerly waited for Asha workers. When most people hesitated, they rushed to the homes of Covid patients. Accredited Social Health Activists (ASHA) who come bearing medicines and comfort are frontline fighters in the field of health along with doctors and nurses.
But ever since Covid fears receded, everyone seems to have conveniently forgotten these selfless workers. Kerala State Asha Workers Union State President M.B. Prabhavati explains the tough life and challenges of an Asha worker.
The mission undertaken by Asha workers during the Covid period was much praised. How difficult was it?
We saw the abject helplessness of humans during the Covid period. Those who were alone would often call at night fearing for their life. We used to comfort them by telling them to stay strong, to drink water, and eat food properly. Our phones would ring incessantly, day and night. There were a few who felt they had become deaf in one ear.
As the Covid pandemic took hold, Asha workers were given so many duties and responsibilities that even 24 hours wasn’t sufficient to fulfill them. They had to deliver medicines to patients, food to special categories and provide kits, etc.
Simultaneously, they had to provide medicines every month for sugar, blood pressure, and cholesterol patients. Asha workers had also assumed a big responsibility of not taking them to hospital during Covid. So they would get their existing registers, visit the OP, consult a doctor, get the prescription and buy medicines from the pharmacy and deliver it to patients at home as a Covid duty.
Every Asha worker was a link to contact any time for help if they knew that someone in their ward had been diagnosed with the disease and to call the family members if they had any needs. With the arrival of the Covid vaccine, Asha workers were also assigned the job of vaccinating people in the respective wards.
What are the problems faced by Asha workers?
Our field of work is public service and we do it voluntarily. However, at times, I get teary-eyed. I am not doing this expecting any reward. But when you see a certain yardstick, you do get the uneasy feeling that you are not being recognised. Asha workers' remuneration is determined by the registration of pregnant women and child vaccinations in addition to the work they do in that ward. In some wards, there are many pregnant women and children, but in some, there are only a few. Accordingly, their wages may also vary.
There are wards in which mostly elderly parents live and though Asha workers do their work efficiently, they will get a meager pay. Apart from this, there are Asha workers who are doing a lot of good work in tribal areas. Among these are several people who have carried out special activities like taking pregnant women to hospitals at night and helping covid patients. Although there is Oorumithram in the tribal areas, most of the tribals depend on Asha workers.
Rain or shine, Asha workers are hard at work. What are the challenges of their job?
They should lead the chlorination programme and assign volunteers during the rainy season. Asha workers can even recommend things like termination of pregnancy in special cases. They are also responsible for administering deworming pills and iron pills once a year as part of the deworming programme. If there are people living alone, they should be given the necessary medicines. If they need assistance, Asha workers should inform the concerned people. In short, they have to keep their eyes and ears open to everything happening in their wards. They have to do any job assigned to them.
Every Asha worker has the responsibility to do the right thing when the government spends money, be it for vaccination, organising a meeting in the ward, or in creating awareness. Asha workers are granted leave with pay for up to one month due to health issues. Leave is allowed for up to a maximum of three months. If there are no Asha workers in that ward, people from nearby places are required to help with the activities.
Very often Asha workers are witnesses to painful and cruel experiences in life. How do they react during those instances?
At times, Asha workers also witness unfortunate things. In 2012, a 10-year-old girl in a ward was found to be nine months pregnant. The family had kept it a secret. As soon they heard about it, they informed the child line. It became a police case. In this case, the child's father was alleged to be the accused. That day I stayed with the child and took her to a government hospital. After her delivery, the baby was placed in the Thiruvananthapuram Child Welfare Committee and the girl was handed over to the Mahila Mandir. Around six months ago, I received a summons related to that case. I am the witness. There was also a situation where I had to go to court for the first time and testify. When the DNA test was done, it was proved that the accused was not the father. It was a horrifying experience. After the age of 18, the girl was taken away from the Mahila Mandir by her relatives. Now no one knows where the child and the mother are.
Asha Workers are always dealing with people. Have there been instances when you have felt tired of this job?
So many times! There are rare occasions when an Asha worker loses her temper while responding to a caller. Immediately complaints pour in. They are only prepared to hear one side of the story. Suppose you get a call when you are going through a bad time and you raise your voice impulsively, the caller will not be empathetic. Till then, Asha workers would have given them all the help they needed. But a stern word and that’s it. Many Asha workers do confess that they feel pained by this insensitivity.
Who is ASHA? And how many Asha Workers are there in Kerala?
Asha’s are certified social health workers appointed in each village as part of the National Health Scheme. Asha workers started their operations in 2005. It was in 2007 that they started their workings in Kerala. The state government aimed to have one Asha worker for every thousand people in Kerala. Those who have done voluntary work in connection with the Kudumbashree are selected as 'Asha'. The basic educational qualification is 8th grade. And you need to be willing to do voluntary work. The appointment of 'Asha' is done through interviews conducted by the Panchayat and Primary Health Centre. Women from the respective rural areas are trained and employed as Asha workers. It works under the Social Welfare Department of Govt. It is estimated that there are around 25,000 Asha workers in Kerala. They are expected to report all health issues in a ward to the concerned department.
What is the job of an Asha worker?
Asha workers were initially employed to take care of mothers and children. When a woman becomes pregnant, everything has to be taken care of, from registration to delivery. Asha workers should ensure that the vaccinations of children up to the age of 15 are taken correctly and also submit a report on the same. With each passing day, Asha was tasked with the entire field of epidemic prevention work. Asha is also responsible for handling duties including nutrition day, meetings and operation at primary health centers.
There were some complaints regarding the salary of Asha workers. How are their wages determined? What are the disadvantages?
There are specific conditions regarding the work to be done by Asha workers and their wages are fixed accordingly. An 'Asha' gets Rs 6000 per month as an honorarium. At present 10 criterions are handed over to these workers. Registering pregnant women in their respective wards, doing one palliative duty in a month, immunization duty of children, Panchayat review, hospital meeting, one nutrition day in Anganwadi centre in a month and field visit to name a few. Whatever programme comes up in the ward, the Asha worker should be at the forefront.
Health information of contracted workers should be investigated, field visits should be made and doxycycline, a prophylactic pill, should be given in case of rat fever. And not just that, they should also make sure that people take the pill and sign on a special form. A clear reason must also be obtained from those who do not take the medication. Whether it is rat fever or dengue fever, if the disease is confirmed in a ward, field visit is mandatory and chlorination works should be done in that area.
Asha benefits only if a woman registers within the first three months of her pregnancy. An Asha worker initially gets Rs 300 when she registers a pregnant woman. Once they are registered, they should be given folic acid tablets and special books. If they do not have a bank account, we should help them to open one. If the delivery takes place in a government hospital, the Asha Worker gets Rs 300.
By registering the details of each vaccination of the child up to the age of five, the Asha worker will get Rs 20 for each jab. It is the duty of Asha workers to call them every month and remind them about the injections/vaccinations. They should call and enquire whether the injection was taken and in which hospital it was taken. They should be informed about the day of vaccination at the primary health center. You can get 20 rupees only if you write down where and on what date the injection was taken.
Are there any irregularities in fixing wages according to the job?
Diabetes screening camps should be organized for people aged above 30. Asha gets Rs 100 for organizing a class in a ward for a month and Rs 600 as honorarium. They get Rs 100 per day and an honorarium of Rs.600 for palliative duty. They will have to take OP duty for two days in the hospital. If you take two duties, you get 1200 rupees. UHAD registration has been computerized at Family Health Center locations. They need to take the OP receipt there. And also need to collect and issue UHAD cards. There are people who are doing five or six duties even though they are expected to do just two in a month. After all, cards should be available to everyone.
They will also be assigned the Covid vaccine duty. A person should assist with registration in the vaccination room. Similarly, tokens should be given to visitors. They will receive a monthly honorarium of Rs 6000 rupees if the work is done appropriately. Apart from this, all the houses in the ward should be visited within three to four months. A ward can have 350-500 houses. Asha also gets 2000 rupees for visiting houses and seeking health information. Pregnant women, palliative patients and those living alone should be visited every month. It is purely based on the reports given by them that the concerned officials are able to figure out the issues in a place and take necessary measures. They are also required to detect congenital diseases and deformities of infants and report them to the RBSK nurse. That means an Asha worker will get a fixed monthly income of Rs 8000.
A record should be prepared every month on the number of pregnant women in the ward, and information on contagious diseases like dengue fever, rat fever etc. This should be reported to the ward member and ward committees.
Asha workers are those who work tirelessly without a break. Are there enough benefits for them?
I am afraid the answer will be no! Because if an Asha is unable to attend the panchayat level review or hospital meeting on a particular day due to an unavoidable reason, the honorarium of Rs.600 and allowance of Rs.100 will not be paid. They would have worked 29 days in a month, but the loss of that one day's inconvenience is Rs 700. This has to change. The salary they get in hand is Rs.6000+ Rs.2000. All other allowances are fixed according to the activities of each ward. It is difficult to continue with this salary in the current situation.
A good amount of money is spent per month on travel itself. Even if there is one PHC in a panchayat, people in different wards often rely on auto-rickshaw to reach this PHC. There are places where bus facilities are limited.
CITU's slogan is that all workers should get Rs 23000 per month. If not that much, there is a demand to increase the honorarium a little more. They are getting an allowance of Rs 1200 for Onam. Asha workers have been requesting the government to increase it to at least Rs 5000. None of the elected representatives try to understand the problems of Asha workers. They in turn are wondering why we aren’t coming to the panchayat once a month. We need an answer on how we will overcome this if we are unable to attend for some reason such as death or hospital emergency. Recommendations for this have been submitted to the government. Every Asha worker is hoping that there will be a solution to this problem.