The Indian public health system is vast. At the state level, it reaches into each district, every block and village. Ultimately, the touchstone of the strength of a health system is whether basic health services are available and delivered with quality in every village. Three female health workers play a crucial role in making this happen. The ANM operates from a basic health facility known as the sub-centre. She is responsible for four to six villages, located anywhere up to 20 kilometres from her facility. The ANM sees patients at the sub-centre and visits each village once a month, on the VHND. On that day, her main task is to vaccinate babies and do a health check on pregnant women. She refers complicated cases to government health facilities beyond the sub-centre.
The AWW oversees an anganwadi (crèche), where preschool children in the age group of three to six years get a hot cooked meal, learn the alphabet and play. She keeps track of the growth and weight of the children. She also identifies any woman whom she sees as a “probable pregnancy”, and informs the ASHA. She begins giving the woman her rations right away. The ASHA pays home visits to check on the health of each family member. She makes her own assessment of “probable pregnancies”, taking note of the cases that the AWW has already flagged for her attention. She marks all these cases to the ANM to confirm the pregnancy. The ASHA begins counselling and ensures that the woman takes her Take Home Ration (THR) even before her pregnancy is confirmed. She measures malnutrition in children using a Mid-Upper Arm Circumference (MUAC) tape and ensures that every newborn gets Home-based Newborn Care (HBNC). She, like the AWW, is also from the village.
This is a well-designed system for village-level maternal and child healthcare. The ASHA and AWW both monitor the health of women and children with copious record-keeping and report these cases to the ANM. The nurse will see those beneficiaries on the VHND at the AWC. In difficult cases, she will visit the houses personally. If the system runs perfectly, there should be few maternal and child deaths, or illnesses, within the community.
We coined the term “AAA workers”, to refer to the three health workers as a unit. On our first visit, we always try and do a leisurely village walk, noting interesting aspects of village life, picking up clues, and talking to the locals. We did that in Jhikri Kalan, accompanied by the ASHA, who was received affectionately in several houses. We reached the khanjar basti section of the village, which is located some distance away from the main village. The ASHA said she would not join us as she had some other work. A local who came up to us warned us that this section of the village could be dangerous (“khatra hai yahaan”). He said the people there made their living from theft and criminal activities. He cautioned us not to carry money or wear a watch.
Once listed under the Criminal Tribes Act, the community is stigmatised. They are mainly nomadic people – villages do not take them in, and they make their homes outside the village’s borders.
The khanjar basti in Jhikri Kalan is a scattering of thirty-three huts around two mud lanes on a vast open field. The huts are dilapidated, held up by spindly poles and patches of blue tarpaulin. When they saw us, even at a distance, people began to move away quickly. They seemed fearful. We approached some older people. They glanced at us and turned away. Finally, a wizened old woman spoke a few words to us – she shook her head when we asked if she had met the ASHA. The village school was just outside the main village.
At the AWC, we sat on the floor to talk to the AAA workers. We asked if we could look at the copious records they maintained. Comparing their bulky registers, we saw many discrepancies. Seema, the ASHA, did not know that Rukmini, who lived in house number 8, was pregnant. Otherwise, she would have counselled her on all the dos and don’ts of pregnancy. Ritu, the AWW, knew that Rukmini had missed her last two periods, and she had put her down as a “probable pregnancy”. She told Rukmini, who probably didn’t understand. She didn’t start her on the THR.
She didn’t inform Seema about this probable pregnancy, or Gracymol, the ANM. So, Rukmini would have missed out on the counselling and THR that was her due till she became visibly pregnant, and someone noticed Rahul, age two, lived in house number 52. He looked malnourished, so Seema, the ASHA, measured his growth status using the MUAC tape. This confirmed that Rahul was mildly malnourished – however, with the right feeding, he could be pulled out of a downward spiral of malnutrition, illness, and even more malnutrition.
Seema assumed that this would happen at the AWC where Rahul had started going – one of the few children from the basti who did. After all, there he would get a hot cooked meal every day, and Ritu, the AWW, could counsel Rahul’s mother about his feeding. Ritu took the children’s weight routinely using a weighing scale. She marked his weight as normal. Seema, however, informed the ANM about Rahul, based on her measure. The ANM examined Rahul and instructed the AWW to take heed. We asked, gently, why there were such discrepancies.
And could it be that some cases were being spotted too late, or even missed entirely? We asked what if there was a pregnant woman who was not on the Due List? The ASHA said that did happen at times because some women didn’t know that if they missed their period, it could be that they had conceived.
We asked about children who were malnourished. That process likely started a long time earlier, when the baby was unable to get breast milk. The women nodded – yes, that happened. The AWW said some families didn’t send their children to the centre. They didn’t want their child eating with low castes.
Some Dalits didn’t send their children because they feared they would not be treated well in the AWC. The department never replaced Ritu’s faulty weighing machine, though she had reported it many times, and now she had no option but to use andaza.
We had just walked through the complicated maze of the village – how could anyone accurately know who out there was sick? I remembered the child staring into the distance that morning. He might have been playing and laughing like the other kids in the room if someone among the three women had spotted him early. The ASHA spoke of her workload, of how long it took to go from house to house – she said she had a small baby at home and that he also needed attention, didn’t he? She said, “Sir, I am not a doctor, I can’t always say if a woman is pregnant or a child is in danger.”
The AWW’s words came out in a rush, “Sir, you have seen today how much work I have, running the centre, so many children and a hot mid-day meal for each.” The ANM’s voice trembled as she spoke. She said she oversaw five villages, scattered over a long distance. The government did not provide a vehicle, requiring them to use public transport, which was irregular. So, she depended on her husband to drop her off in some villages, but he had his own work, too, and she could not visit all the villages. She told us about her day: waking up at 5 a.m. to attend to the house – cleaning, cooking breakfast, getting her two children ready for school. She would end her day after 10 pm, having finished a gruelling day’s work, and come back to make dinner and snatch some time with her family.
Excerpted with permission from How The Light Gets In: A Journey Through the Struggles and Hopes of India’s Poorest Mothers, Ashok Alexander, Penguin India.