India’s Community Health Workers Were Overworked. Then Came a Pandemic.

It’s been nearly 14 years since, and the role’s most important aspect— that of availability—remains the same. “There is no fixed timing. We have to be available, whenever it is required,” she said.

Before May this year, her duties involved providing maternal and child health care, motivating women to give birth in hospitals, bringing children to immunisation drives, encouraging family planning and supplying the government with on-ground health data. “We were always overworked and the money doesn’t do any justice to the amount of labour we put in,” lamented Soreng. 

Since the COVID-19 outbreak, responsibilities have soared exponentially for the 40-year-old community health worker, who works to serve two villages comprising a total population of more than 1100 people in Lakhimpur district of Assam. 

Now, she also has to go door-to-door, making people aware of COVID-19 and its norms such as hand-washing, social distancing and monitoring their health. She starts on foot at 10 am every morning and covers 15-20 houses within a span of seven to eight hours by traversing unpaved, slippery and muddy roads. ASHA workers are expected to observe those in home quarantine, checking on their family members, and tracking others who might be showing any signs of fever, cold and cough, while maintaining a “three-metre-distance” and raising the importance of hand hygiene. 

Soreng is among India’s approximately 900,000 community health workers serving as an interface between the country’s many communities and the public health delivery system in these difficult times. They are known as ASHAs: Accredited Social Health Activists, inducted by the Government of India’s Ministry of Health and Family Welfare as part of the National Health Mission (NHM). 

“Their experience of several years has been useful in enabling contact tracing,” said the executive director of the National Health Systems Resource Center (NHSRC), who did not want their name used for this story. The NHSRC serves as the Indian government's technical support for the NHM. 

When Ebola was declared as a public health emergency of international concern in 2014, it was the community health workers who played an important role in containing its spread in Nigeria. 

In several official languages of India, the word “asha” translates to hope. Purnima Sarothi, 30, of Dufflaghur tea estate in Sonitpur district of Assam said that the ambulance in the tea garden can be used only with the manager’s permission. “Sometimes they don’t let us use it and at other times, it is out of service. When someone needs the ambulance, I have to shell out around INR 200 (US$2.66) to help them get a private vehicle to the nearest civil hospital which is about half an hour away,” she said. This extra money is almost never refunded; Sarothi is paid INR 3,000 (US$39.98) monthly for her work as an ASHA.

If the delivery requires a C-section then the patient is referred to a hospital in Tezpur town, which is three hours away from the tea estate. “Sometimes the mothers insist that we stay with them in the hospital until they are stable,” Sarothi added.

Assam has the highest maternal mortality rate among Indian states, and it’s especially high in its tea estates, revealed a study published in February 2019. The study found that 69 percent of all deaths were among women of the tea gardens. Assam’s MMR of 237 is almost double the national average of 130. According to the World Bank, India accounts for 17 percent of all maternal deaths in the world. 

Over the years, ASHA workers have been considered instrumental in making reproductive, maternal and child health care accessible to people in rural areas and slum clusters of urban areas. While stressing that maternal healthcare is “topmost priority”, Lakshmanan S, director of Assam’s National Health Mission, said the nature of the pandemic is such that not only maternal health but even general health is getting affected. “There is tremendous pressure on the health system,” he said. 

A regular day for Sarothi starts at 10 in the morning—she would then set out on her bicycle covering around 3 km across six villages within the tea estate. Since April, she has also been doing COVID-19 rounds. Among all her duties, spreading awareness on COVID-19, she said, has been the most challenging. “Most often people don’t listen, they don’t take me seriously enough, they believe they won’t get infected.” Sarothi had received a bottle of sanitizer and about seven to eight masks at the beginning of the pandemic. “The sanitizer is over. When I asked them for more, they said it's out of stock, so I bought one myself,” she added.

Soreng had to stitch her own masks. “I got only one during our COVID-19 training in April,” she said, adding that she still has the 500ml sanitiser that they gave her, which she has been using rather judiciously.

Although considered volunteers, ASHAs were roped in for India’s COVID-19 surveillance duty in a rush and were  “trained overnight”, said the executive director of NHSRC. “In states that already have a high burden of maternal and child mortality, how much work can you give a voluntary worker? So, one would be cautious in adding to her workload,” they said. 

Soreng said she didn’t receive any training in the beginning of her COVID-19 work, but had attended a day’s session after a month at the nearest public health centre. 

Sarothi caters to 3,500 people. “I have to check on returning migrant workers who are in home and institutional quarantine, and also make sure that their families are taking precautions.” She now hopes another ASHA would share her workload. She requested the public health centre for an extra pair of hands three months back but is yet to receive a response. “It’s not possible for me to continue doing all this work all by myself,” she said. 

In April 2020, the Government of India announced a COVID-19 incentive of INR 1,000 (US$13.30)—to be paid from January to June—to the ASHA workers for their COVID-19 work under the India COVID-19 Emergency Response and Health Systems Preparedness Package.

None of the three workers in Assam VICE News spoke to have got their due. “I did not even understand how one is supposed to procure that amount. I usually receive INR 3,000 (US$39.90) as monthly pay. Then, I heard about this ₹1000 incentive, which I haven’t got yet,” said Alka Mondal, 39, another community health worker from a tea estate in Assam. 

There is a disparity in the pay of the ASHAs across all Indian states, said Dr Kavita Bhatia, an independent researcher based in Mumbai, who has been working for the professional rights of community health workers in India. “Whatever they are getting is extremely inadequate,” Bhatia added. 

The money paid will never be enough, said Lakshmanan S. “Every health department member is working many more hours than their normal routine due to COVID-19. Their salary and the wage still remains the same.”

Besides low wages, extra work, lack of protective equipment, there is also the stigma that they have to face from families and relatives due to their community contact. Soreng says her family members were wary of her going out for COVID-19 duty. “They were scared that I was putting myself and them at risk. But who knows who is carrying the virus and who isn’t. I can hate the virus but I can’t hate human beings for it.” 

Assam has not released data on ASHA workers testing positive, but at least 11 have been infected across states like Punjab, Gujarat and Odisha.

There are also unfounded fears among several communities in rural India that they will be taken away from their families by the ASHA workers and will be hospitalised, said Dr Bhatia. “They are not aware that the ASHAs are working from the government’s side. Therefore, a lot of their frustration is vented on the ASHAs.”

The pandemic has forced everyone to look inwards and there “might be a rethink” in the ASHA programme, said the executive director of NHSRC. “Unless we don’t start from the lowest level, we are not going to get information related to contact tracing, quarantine, immunisation (etc).” The official also said that the pandemic has been particularly bad in urban areas where ASHAs have been valuable. “The urban ASHA program needs to be strengthened and expanded,” they said.

Yet, underneath all the hard work, Soreng believes that it’s “worth it.” “Many are still working tirelessly to save mothers from dying.”

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