Fifteen-year-old Sanjana remembers the night her mother Pushpa Devi died. It was December 31, 2016, and very cold. Thirty five-year-old Devi had accompanied a woman who lived in her village Abhaypura in Akola block of Agra district to the Community Health Centre in the area. The woman was in labour and it was Devi’s job as an Accredited Social Health Activist or ASHA to get her to the health facility in time to have the baby. But Devi, who was made to wait overnight on a bench outside the health centre, died because of the freezing temperatures. She was later found to have had a brain haemorrhage.

“What irony that she died at a hospital, while other people die because they fail to reach there,” exclaimed Sanjana.

Sanjana now takes care of her four siblings. Devi’s family says that staff at the community health centre collected Rs 5,000 as compensation for their loss. Devi’s husband Shailendra Kumar said that the district sub divisional magistrate also promised the family compensation from the government, which never came.

“I had requested the auxillary nurse midwife and doctors to recommend financial help [from the state government] for Pushpa’s family but they all claimed to have no role to play in forwarding the proposal,” said Manjari Lata, the 60-year-old ASHA Sangini who monitors the 20 ASHA workers in the seven villages of the Malpura block in Uttar Pradesh’s Agra district. “The government applauds the success of their health schemes and look what amount they had calculated for the life of an ASHA, the backbone of maternal and child birth schemes under the National Rural Health Mission.”

Kumar is a daily wage labourer who earns about Rs 200 a day. He said that Devi decided to work as an ASHA to help women in the village. He was against the idea since the job did not pay much.

Running on incentives

ASHAs are community health workers under the umbrella of the National Rural Health Mission that was launched in 2005 by the Ministry of Health and Family Welfare. Each ASHA is selected from the local community and trained as a health educator. The function of ASHAs is to create awareness about health, mobilise the community for local health planning and increase utilisation and accountability of existing health services. Much of India’s progress in reducing maternal and infant mortality in the past decade has been attributed to the work of ASHAs.

ASHAs are contract workers who are given incentives based on the number of cases – mostly institutional deliveries – that they take care of. For instance, an ASHA worker who brings a woman in labour to a healthcare facility gets paid Rs 600 in Uttar Pradesh.

There are about 1.37 lakh ASHA workers in Uttar Pradesh. In May, an ASHA worker stopped Uttar Pradesh Chief Minister Yogi Adityanath’s motorcade outside the Azamgarh district hospital. The woman was trying to draw attention to the fact that she had not got the payment due to her for six months.

Hundreds of ASHAs recently gathered outside the Gorakhnath temple in Gorakhpur, of which Adityanath has been head priest, during his visit there on May 25. The ASHAs were there to demand permanent posts and fixed wages. The chief minister did not meet the ASHAs that day but in his speech said that their “Acche Din” have arrived and that they will get better benefits soon.

Anita Devi, the ASHA in Garkatua village of Agra district weighting a newborn. Photo credit: Ishita Mishra

An ASHA gets Rs 600 for every woman she takes a woman for an institutional delivery. This is divided as Rs 300 for antenatal care during pregnancy and Rs 300 for bringing the woman to a health facility for delivery of a baby. Antenatal care involves counseling the woman and making sure that she takes her iron folic tablets, goes for routine checkups, and calling an ambulance when the woman goes into labour.

“We are the one who run in the sun and stay up during nights,”said Sunita Rai, an ASHA workers from Gorakhpur. “We walk between 10 and 15 kilometers every day just to ensure every pregnant woman gets proper treatment and counseling as we can’t afford to commute through public conveyance.”

Rai also complained that ASHAs often had to pay to hire private vehicles to take local people to hospitals since government ambulances were not always available.

Similarly, ASHAs get paid Rs 150 to help conduct vaccination drives in a village and to get all its children immunised.

“Does the government want poor village women to do charity?” asked Rai. “We all are out for work and we expect atleast a fixed amount of salary, whatever government thinks we deserve.”

The state government has given ASHA workers mobile phones to help them carry out their duties. This includes monitoring and updating the web enabled Maternal and Child Tracking System on the progress of pregnant women and nutrition of children. Munni Kumari, an ASHA from Deori village of Fatehpur district of eastern Uttar Pradesh, complained that in the age of unlimited talk time, the government allows ASHAs only 100 minutes every month to communicate to those in need of healthcare in a village.

Besides taking care of pregnant woman and promoting immunisation ASHAs are trained in first aid to treat basic illness and injury. They are charged with keeping birth and death records and improving village sanitation. ASHAs also stock essential provisions like oral rehydration solutions, iron folic acid tablets, chloroquine to treat malaria, disposable delivery kits, oral contraceptive pills and condoms.

Manjari Lata (right), ASHA sangini from Agra with a pregnant woman. Photo credit: Ishita Mishra

Corruption in the health system further eats into the meagre fees that an ASHA gets. Tarrannum, an ASHA worker in Rudayan village in Hathras district of Uttar Pradesh, said that she had to bribe security, auxillary nurse midwives and nurses’ each time she took a patient to the hospital.

“If we are paid Rs 600 for a delivery, we have to give Rs 100 as commission,” she said.

The ASHAs are paid their money online, but since this is a long and bureaucratic process, they end up paying money to mediators who help them fill out their online forms and vouchers and speed up approvals needed from doctors and medical officers.

“The peons charge us money when we deposit our vouchers,” said Tarrannum. “If we do not bribe them, they will not send the vouchers for further clearance,” she added.

Permanent positions?

Agra’s chief medical officer Dr BS Yadav feels ASHAs can be given fixed payments but does not want them to become permanent employees under the National Health Mission. “I can tell you that 50% of ASHAs working in scores of villagers in Agra are totally inactive,” he said. “The inactive ASHAs either don’t work or work as agents of private hospitals. If such people will be given fixed wage, this will be a huge loss for the government.”

Yadav suggests that ASHAs’ performances may be tracked over time and deserving workers get fixed wages.

Even though ASHA workers are demanding that their jobs move from being contractual to being made permanent positions, Dr Neelam Singh does not this think this is a good idea. Singh is a gynaecologist and founder member of the non-profit organisation Vatsalya that works to prevent sex-selective abortions.

“Once they will become permanent, they will start behaving like government employees,” said Singh. “An ASHA, if working properly can easily earn Rs 5,000 to Rs 6,000 every month from the various incentives being given to them by the government.”

ASHA worker Nidhi from Kalyanpur block of Kanpur district disagrees. She said that she is unable to make even Rs 2,000 every month and is being pressurised by her husband to find another job. “I don’t want to change profession as I am happy helping women but in this way, I am not able to help my family and kids,” she said.

ASHAs in Uttar Pradesh have long lists of complaints – from doctors being uncooperative to residents in their villages being unresponsive. The state is a particularly harsh on women working in rural areas. A fact finding team investigating the gang rape and death of an ASHA in Muzaffarnagar in January 2016, said in its report that although the National Health Mission is often alluded to as the government’s flagship programme, it has failed in its responsibility as an ethical employer. ASHAs have no support and back-up system to deal with the fallout of their social role as “change agents” in rural areas, and to deal with community reactions to their mobility and public exposure. The report stresses the need to consider the deeply patriarchal system within which ASHAs function in states like Uttar Pradesh.

The name of the ASHA in Varanasi’s Vandepur village happens to be Asha – a word that means hope – and she has only one sentence to describe what she feels about her work. “We are ASHA for others but have no hope for ourselves.”

This reporting project has been made possible partly by funding from New Venture Fund for Communications.