India’s healthcare system houses a three-tiered structure. This includes Sub-centres, Primary Health Centres (PHCs) and Community Health Centres (CHCs) at the primary level, District hospitals at the secondary level and Hospitals at the tertiary level.
In 2005, the Indian government launched the National Rural Health Mission (NHRM) to help the vulnerable sections of society by aiming at the decentralisation of the healthcare system. This mission was launched to achieve the Millenium Development Goals which focused on maternal and child health and nutrition.
It was in forwardance of the NHRM that Accredited Social Health Activists (ASHA workers) were appointed to “act as a bridge between the rural people and the health services outlet.” ASHA workers were given the responsibility of acting as a facilitator for health-care services and as health activists. They were appointed as predominantly female workers who would be the first point of contact for any health-related issues of women or children, especially those who could not or would not access formal healthcare settings.
The role of ASHA workers
The guidelines proposed that ASHA workers would promulgate awareness regarding basic hygiene and counsel women on all factors surrounding sexual hygiene, pregnancy, birth, immunization and care of an infant and child. An ASHA worker, in common parlance, was to act as an educated agony aunt to women and children and could be approached about all issues which might usually be considered taboo in society-- including but not limited to contraception, sexual activities, menstruation and childbirth.
An ASHA worker’s role goes beyond a grassroots level healthworker. They are also supposed to accompany women and children to PHCs and help the village governing bodies maintain records of pregnancies, births and deaths. ASHA workers, as per the guidelines, also have to help the panchayat to develop health plans for the village, thereby, also possess governance roles.
The guidelines required that the ASHA workers be trained for a period of at least two years and their skills be continually upgraded. It was specified that there would be around 1 ASHA worker per 1000 people and in difficult geographical terrains, this could be relaxed to one ASHA worker for the specific population.
While the government gave plenty of responsibilities and numerous roles to the ASHA workers, they made sure to mention in their guidelines, that these workers were just ‘honorary volunteers.’ The guidelines specifically mentioned that these workers would not be salaried employees of the government and would work on an incentive basis. It was also specified that taking the role of an ASHA worker would not interfere with the normal livelihoods of these women.
Being an ASHA worker is not an easy task. Many studies have been conducted to try and understand why women actually are motivated to act as ASHA workers in their community. Some concluded that societal respect, the sense of autonomy were huge motivators and others said that these women took pride in the fact that their efforts were helping their community and the nation as a whole.
Challenges faced by India’s ASHA workers
In a society like India, the ASHA workers face a plethora ofchallenges. Some of these are highlighted below:
1) Women’s right to bodily autonomy: Patriarchy is predominant in India. Women are often considered as the second sex. 51% of the adult female population is illiterate. A combination of these factors often leads to women not having control over their bodies in terms of access to healthcare. ASHA workers have to often squabble with the men in the community to beable to educate the women about their bodies.
2) Women’s right to reproductive autonomy: India’s population often views women solely as baby-makers. The next step, post-marriage, for a couple is to produce an heir to carry on the family name. Women barely have a say in whether and when they want to have a child. Often, male partners participate in birth control sabotage and/or stealthing because they wish to have a child and “solidify” their marriage. When ASHA workers give or talk about contraception to people, they are sometimes called shameless. Other times, men ask them not to teach such things to their women.
3) Overburdening: Theoretically, ASHA workers are not required to perform their duties on a full-time basis. However, especially during the pandemic, the responsibility on ASHA workers has increased. Not only do they have to educate their communities regarding COVID-19, but they also have to ensure people follow safe practices like wearing a mask,washing their hands and maintaining social distancing. ASHA workers are also educating their communities about the need for vaccination and in certain cases soothing people from their fear of needles. They are doing these tasks over and above their daily duties- a major chunk of which is family planning and providing contraceptives. During the pandemic, they were also asked, on multiple occasions, by the government to get surveys filled from all the households intheir community.
4) Minimum monetary support: Though ASHA workers are working tirelessly and round the clock, they barely make minimum wage. Since they are ‘volunteers’ andnot technically employees, the Government is not entitled to ensure that they make minimum wage. Further, to make matters worse, many ASHA workers complain that they are not paid their dues in time and that what they are paid barely compensates for the number of efforts they make.
5) Lack of support from the government: ASHA workers have acted as the frontline workers in the pandemic. They have stepped up to educate communities at large. However, there is minimum support for them from the government. They were promised protective gear, face shields, sanitizers, gloves, etc. However, in reality, only 75% of ASHA workers were given masks, 62% were given gloves, and only 23% received full bodysuits. The others had to improvise and make masks from old clothes and spend their own money on sanitisers.
ASHA workers also complain about the lack of public transport. They face issues in getting to and fro from the areas they are required to cover. They also face problems in taking women from their communities to PHCs. Some ASHA workers have also complained that the difficult terrains in some parts of the country make their job a lot tougher and having more ASHA workers would significantly reduce their burden.
6) Issues of religion and caste: The caste and religion divide in India is very prevalent. Many ASHA workers often hesitate in interacting with people of other religions. They do not wish to interact closely with people of a lower caste and dither in approaching people of an upper caste.
7) Gendered hierarchies: ASHA workers have to talk to panchayat members to help come up with plans regarding the health of the community. However, men in power often question their authority. During the pandemic, ASHA workers were asked to educate people regarding the novel Coronavirus. Many workers reported that men would not listen to them. Therefore, the fact that these frontline workers are women, irks men who further question why they should listen to a woman.
8) Domestic occupations: While many ASHA workers appreciate the chance to go out and help their community and the ability to have a bit of financial freedom, being an ASHA worker requires a lot of time commitment. They have to do their domestic chores like cooking, cleaning and taking care of their kids besides caring for an entire community. This requires a lot of support from their families. They have to also educate their family about their role and its importance in the community.
The way forward
India has the biggest force of Community Healthcare Workers in the world. This force is motivated, to some extent, by altruism and community spirit. With the health infrastructure of the country in shambles, post the second wave of covid, India needs to focus on a bottom-up approach for its health policies.
The government already has a force of women, at the frontline, ready to help rebuild the healthcare system However, policymakers and the Central, State governments need to remember that these women, though not professionally trained in medicine, are their link to the rural communities. The government should ensure that ASHA workers are supported by the State monetarily and that infrastructure is built to support them at the grassroots level if India wants to emerge from this pandemic without an epidemic at its hands.
It will take a long time to eradicate patriarchal norms and male-dominated hierarchical structures in Indian society. A force of female healthcare workers at the bottom-most level of the healthcare pyramid is a welcome step in providing not only bodily autonomy to rural women but alsofinancial independence to the women who volunteer on behalf of the State.
It would be a revolutionary step if states could not only provide better benefits to ASHA workers but also help them receive more formal education and work opportunities. This would not only give them more authority but also ensure that the men in their society respect them.
The State could focus on utilising the passion and talents of ASHA workers to remove the stigma around topics that are considered taboo in Indian society. This would help in population control and better treatment of the girl child in India.
Post the Navtej Singh Johar judgement, the government can also educate ASHA workers on the rights of the LGBTQ+ community so that non-cisgender and non-heterosexual children growing up in the backward parts of India are brought up in safer environments without being subject to medical opinions of quacks who claim that they can ‘pray the queer away.’