This paper tries to investigate the Indian health system from the perspective of an ASHA Worker, India’s women community health volunteers. Being the largest, ASHAs have set a benchmark in the health system. However, the patriarchal structure of medicine places them at the bottom most level of the system. The paper also tries to bring across the overburdening of ASHAs along with issues of accessibility, recognition, acceptance and security.
THE OVERBURDENED WOMAN IN THE HEALTH SYSTEM
About 900,000 Accredited Social Health Activists form of the community of women who work in the favour of institutional health care replacing the system of Dai’s who worked since times unknown at the grassroot levels. National Health Mission started in the year 2005 and was UPA I’s flagship health programme. It aims to make healthcare decentralized and community owned, and brings in funds, personnel, better infrastructure etc. It focussed on under-served regions and populations, both in the rural and urban areas.
An ASHA keeps in check Infant Mortality Ratio, immunization coverage, and institutional deliveries.ASHAs were appointed in rural area at the rate of 1 per 1000 population in the year 2008 and 1 per 2500 population in the year 2015. The role of an ASHA is to act as a link between community and health system. In all, an ASHA is an activist, facilitator and a service provider. Elaborated below are first-hand narratives which speak volumes on their issues.
WHEN SHALL SHARDA RECEIVE HER SALARY? (SHARDA’S Case)
Sharda works as a community volunteer in Murera district of Madhya Pradesh. She has been an ASHA since the year 2008 and was informed about the same by the Sarpanch who filled up the form for her only to find out that she was selected and was asked to join at the earliest. The salary amount as informed by Sharda in her region is Rs. 2000 which she says, is not received by her on a regular basis. There is a lot of discrepancy in the process of salaries. Remunerative benefits are something out of an ASHAs league. Sharda complains that there is a lot of paper work which comes down to an ASHA eventually, because of which important work in the profession is overlooked. During her training which happens in a stipulated time span of six months or so, she noticed that it was a lacunae in the training processes supported by the government. There is a lack of new tools and methods in the training processes.
600 RUPEES FOR A RISKY INSTITUTIONAL DELIVERY
Kamal is a proud husband of an ASHA worker who works in the Agora region of Madhya Pradesh. According to him, due to the kind of job which his wife has chosen, there is a possibility that she leaves the home sometimes at 2:00 pm in the night and that becomes a task because the children have to go to school in the morning and it becomes very difficult to leave children alone at night. ASHAs are voluntary workers so the kind of salary that they receive depends on how well they perform every month. This redemption on voluntary basis is problematic since it allows a space for government interference in the work of an ASHA. Privatization is the root of all problems according to Kamal.
“A woman, once was been looked after in a government hospital but due to her critical condition at the time of the delivery she was transferred to the private hospital. And all of this was asked to be done around 2:00 pm at night,” told Kamal with a sense of disregard. Surveys and register maintenance are other concerns he disapproves of. The stipend is calculated to be about Rs. 600 for each institutional delivery, as and when it is successful and Rs. 150 or so for vaccinations.
JANKI IS SCARED TO TRAVEL AT NIGHT
Janki works as an ASHA since the year 2006-07 and has been rightfully gaining employment through this voluntary work in Richhari region of Madhya Pradesh. For Janki, being an ASHA is as difficult as it is to be in any other profession. Surveys and calculations become problematic for her but she is able to deal with it sincerely. What she is unable to solve is the management of housework and fieldwork. She informed how impossible it becomes for her to travel at night without proper conveyance.
“There is likelihood of sexual harassment and stalking every day,” says Janki. Motherhood and caregiving are related concepts and the work of such a community as the ASHAs make it even more comprehensive and labour some. However, the fact that the labour is less paid or unpaid at times, becomes a point of concern.
UNPAID OR HALF-PAID SOMETIMES
Babita works as an ASHA in Datiya region of Madhya Pradesh who became an ASHA after an Aaganwadi worker who she lovingly calls didi asked her to fill the form which the government had released. She explains how there is triple oppression in the work of an ASHA.
“If there is a call for delivery at midnight and I ask the patient to reach the hospital before I come, there is a possibility that the patient does not agree to my suggestion and instead does not go and the case worsens, it is most likely that we will be scolded from all sides. The ANM and the patient, both the parties put heavy blames on us and we are left unacknowledged,” said Babita.
About the salary discrepancy, Babita mentioned that it is very usual that they remain unpaid or half-paid sometimes. It depends on how much work is done by the ASHA every month. It is also very unfortunate that sometimes the work is so much that they come back home around 8:30 in the nigh whereas their shift requires them to leave their workplaces at 6:00 pm in the evening.
WILL WAGE-GAP FEED CHILDREN?
Archana has been an ASHA worker for some years now. Earlier, she used to help the aanganwaadi workers in all the tasks. Amongst all the participants, Archana remains highly qualified and had done her Masters in Arts. After she received a joining letter, she promised to serve the women of her community with full dedication.
“Once, there was a nearby area where lived a very poor family. The woman was having labour pains for the first time. After Archana had stayed with her for some time, she left because she had to prepare food at home. At around 12:00 pm she received a call wherein the mother-in-law of the woman started howling. She regrets that she could not reach the woman’s place on time that day since there was unavailability of any mode of conveyance. The child died at around 2:30 pm in the emergency ward,” told Archana.
CRASS COMMENTS AND USUAL STALKING
Neelam works as an ASHA in the Datiya Village of Madhya Pradesh. She is metric pass and loves her job just as much as she loves her children. The eligibility to be an ASHA as told by her is that a woman has to be married and at least a high school graduate. Initially, the fact that the job required her to be available 24*7 was problematic since her in-laws were not approving of the same. However, with will and might she discovered ways to manage both her home and the world. On being asked if she faces a lot of difficulties in her job, she mentioned that the foremost problem is that of absence of the supervisor. In the absence of the supervisor, most of the work is shared in between the ANM and herself which goes on to become a lot of work eventually. The other problem faced by her on everyday basis was the inability to hold a conversation with men on the issues of sexuality and reproduction. It becomes most likely that she is targeted with clear comments and usual stalking.
“Sometimes, the vehicle which is supposed to take me to the woman who is in labour pain, does not arrive on time and so it causes a lot of problems,” says Neelam.
Due to sexual division of labour, it becomes easy to sanction responsibilities based on the perceived meanings of sex. One, a lot of paperwork qualifies for the fact that ASHAs become a sight of exploration and overburdening in true sense. Then there is a certain eligibility criteria which should be met in the case of the ASHA worker. An ASHA has to be married and should be a high school graduate. However, when it comes to the payment procedures, the labour of the ASHA becomes voluntary. This becomes highly problematic. Health is one such patriarchal institution where all the major authority is in the hands of the man.
*Chaitali Pant is a student of Gender Studies at Jamia Millia Islamia University in New Delhi