India’s Frontline Health Workers Laboring Through the Lockdown

“We have gone through a lot of strain during the lockdown. Apart from the Covid-19 surveys, I handled 27 childbirths from just April to July. Right from the mother’s check-up to taking her to the primary health centre for delivery, I was there for all of them,” says Tanuja Waghole, an ASHA worker – accredited social health activist – in Nilegaon village of Osmanabad district.

After the lockdown was imposed at the end of March, Tanuja began waking up at 4 a.m. (instead of her usual 7:30) to complete housework and cook for her husband and two sons, before setting out every day. “If I don’t start by 7.30, I won’t get to meet everyone. Sometimes, people leave their homes early just to avoid us and our instructions,” she says.

And instead of only 3-4 hours of ASHA work a day for around 15-20 days a month, 40-year-old Tanuja, who has been an ASHA since 2010, is now on her rounds for about six hours a day nearly every day.

The Covid-19 survey began on April 7 in Nilegaon village of Tuljapur taluka. Tanuja and Alka Mulay, an ASHA colleague, have together been visiting 30-35 homes in their village every day. “We go door-to-door and check if anyone has fever or any other coronavirus symptom,” she says. Anyone complaining of fever is given paracetamol tablets. If they have coronavirus symptoms, the primary health centre in Andur village, 25 kilometres away, is alerted. (The PHC then sends someone to the village to collect samples for a Covid test; if the test result is positive, the person is moved to the Rural Hospital in Tuljapur for quarantine and treatment.)

The ASHA workers take almost a fortnight to cover all the households in the village –then they start again. On the periphery of Nilegaon are two tandas – settlements of the once nomadic Laman community, a Scheduled Tribe. The total population of the central village and tandas is about 3,000, estimates Tanuja. (Census 2011 lists 452 households in Nilegaon.)

As part of their regular duties, Tanuja and her colleague have also been monitoring the health of pregnant women, assisting with childbirths, and regularly measuring the weight and temperature of newborns. Senior citizens are given special attention, adds Tanuja. “For all this, what we received from the government was a cloth mask, a bottle of sanitiser and Rs. 1,000,” she says. The mask reached her on April 6, just a day before she started the survey, and the money, an incentive for the survey, was given only once (in April).

Unlike frontline workers in city hospitals, the ASHAs – or ‘community health volunteers’ – haven’t received any other equipment for personal protection. Not even an additional mask, says Tanuja. “I had to buy a few masks for Rs. 400.” She is paid a monthly honorarium of Rs. 1,500 – the same since 2014 for Osmanabad’s ASHA workers. And she earns another Rs. 1,500 a month for “performance-based incentives” under various national health programmes. These rates too are the same since 2014.

But ASHAs have a vital role in helping people in rural areas – especially women, children, and members of vulnerable communities – to access healthcare services. They also create awareness about health, nutrition, vaccines and the government’s health schemes.

Their close interaction with the community places them at greater risk while conducting the Covid-19 survey. “I come in contact with many people everyday. Who knows whether they are positive or not? Is a mere cloth mask sufficient?” asks Nagini Survase, a 42-year-old ASHA worker in Dahitana village, Tuljapur taluka. The ASHAs in her taluka were given an infrared thermometer gun and pulse oximeter only in mid-July.

After the government announced a lockdown on March 24, managing the return of migrant workers was also a concern for ASHA workers in Osmanabad. “Almost 300 migrants returned to our village between April and June. The number trickled down and then stopped by the end of June,” says Tanuja. The majority came from Pune and Mumbai, 280 and 410 kilometres away, where coronavirus infections have been among the highest in the country. “But despite repeated instructions to quarantine at home for 14 days, many would go out.”

In Tuljapur taluka’s Fulwadi gram panchayat, about 21 kilometres from Nilegaon, the first Covid survey was conducted from mid-March to April 7. “In that time, 182 migrant workers returned to Fulwadi. Many travelled on foot from Mumbai and Pune. Some entered the village at midnight, when nobody was keeping a vigil,” says Shakuntala Langade, a 42-year-old ASHA worker. The panchayat is home to 315 families and about 1,500 people, she adds. “Before April 6, when the survey was already on, I didn’t receive anything for protection – no masks, gloves or anything else,” Shakuntala says.

It is difficult for ASHA workers to keep track of everyone coming in, and keep checking that they self-quarantine, adds Anita Kadam, an ASHA facilitator who works at Kanegaon PHC in Lohara taluka of Osmanabad district. “Yet, our ASHAs do their tasks without complaining,” she says. Anita, 40, supervises the work of all 32 ASHAs reporting to the PHC. For this, she earns Rs. 8,225 per month (including all allowances).

At the end of March, a Corona Sahayyata Kaksh’ (help centre) was set up in every gram panchayat of Osmanabad district. It was led by the gram sevak, officials of the panchayat, the local government school’s principal and teachers – as well as ASHAs and anganwadi workers. “Our ASHA team is the major support to the Corona Sahayyata Kaksh. They gave us daily updates on people entering the villages,” says Prashantsingh Marod, block development officer of Tuljapur.

At first, the 1,161 ASHA workers of Osmanabad (till 2014, says the National Health Mission Maharashtra site; an organisation working in the district puts their present number at 1207) didn’t receive any formal training for managing the pandemic situation. Instead, they received a just booklet on the coronavirus compiled by the district collector’s office. It contained guidelines for physical distancing and home quarantine measures. On May 11, the ASHA workers had to attend an hour-long webinar meant to prepare them for the pandemic and the return of migrants from the cities.

It was conducted by ASHA facilitators, and gave an overview of Covid-19 symptoms  and steps for home quarantine. The ASHAs were told to maintain a record of everyone entering their village, and to approach the police in case of any dispute. “We were strictly instructed to take anyone with Covid-19 symptoms to the PHC,” says Tanuja. The session also included discussions on how to handle pregnancies during Covid-19, and the health of children and senior citizens.

But the ASHAs wanted to highlight more pressing concerns at that time. “We asked for better medical kits, hoping the facilitators could voice our demand at the PHCs,” says Tanuja. They also raised another major issue: the lack of vehicles to transport patients. “Emergency transport facility is not available at the nearby PHCs [Andur and Naldurg]. It is difficult for us to take patients there,” Tanuja says.

In Dahitana village, Nagini tells us about a woman, seven months pregnant, who had returned from Pune with her husband. He had lost his job at a construction site during the lockdown. “It was in the first week of May. When I visited her to discuss home quarantine, I noticed that her eyes were drooping and she looked pale and weak. She couldn’t even stand properly.” Nagini wanted her to immediately visit the PHC. “When I called the PHC for the ambulance, it wasn’t available. The PHCs of four talukas share two vehicles. We somehow arranged a rickshaw for her.”

Tests at the Naldurg PHC showed that her haemoglobin level was very low. Anaemia is common among women here, says Nagini, but this was a case of severe anaemia during pregnancy. “We had to look for another rickshaw and take her for blood transfusion to the Rural Hospital in Tuljapur, around 100 kilometres from Dahitana. The total rickshaw fare came to Rs. 1,500. Her financial condition was weak. So we raised money from the Corona Sahayyata Kaksh’s members. Isn’t it one of the main duties of the government to ensure enough ambulances?”

At times, in such situations, the ASHAs workers put in some of their own money too – though they cannot afford to. Nagini is the sole earner in her family after her husband died from an illness 10 years ago; her son and mother-in-law depend on her income.

In Fulwadi, Shakuntala had to supplement her income during the lockdown (and she hasn’t yet received her dues for June and July). “My husband, Gurudev Langade, is a farm labourer. He earned a daily wage of Rs. 250, but he hardly got any work this summer. The months of June to October are when he gets maximum employment,” she says. The couple has two daughters, aged 17 and 2, and Gurudev’s parents live with them too.

From May to July, Shakuntala managed to earn a little extra by cooking meals in her village for a project run by the Andur-based HALO Medical Foundation. This not-for-profit organisation had approached anganwadi workers and ASHAs willing to cook meals for a fee. The groceries were supplied to them. “We identified 300 people who were in extreme need of support in Lohara and Tuljapur talukas. We distributed food from May 15 to July 31,” says Baswaraj Nare, a member of HALO.

“It helped ASHAs like me who receive a nominal, insufficient salary. I got Rs. 60 a day for cooking and delivering two meals and a cup of tea [per person]. I cooked for six people and earned Rs. 360 a day,” says Shakuntala. In 2019, she had taken a loan of Rs. 3 lakh, on 3 per cent interest, from a private moneylender, for her 20-year-old daughter Sangeeta’s wedding. She has paid back Rs. 80,000, not missing instalments even during the lockdown.

“My mother-in-law was concerned because I was working during the pandemic. ‘You’ll bring this illness home’, she said. But she didn’t realise that if I looked after the village, my family wouldn’t starve,” says Shakuntala.

Tanuja too earned Rs. 360 a day from cooking meals for the same programme. Every day, she’d finish her ASHA duties, come home to cook and then deliver six tiffins. “After giving them tea at around 4 p.m., I would go to attend the corona help centre’s daily meeting,” she says.

Tuljapur taluka had 447 Covid-positive cases and Lohara had 65, as of August 13. Dahitana has reported 4, while Nilegaon and Fulwadi haven’t had a positive case yet, say the ASHA workers.

On June 25, the Maharashtra government announced an increase in the monthly honorarium – by Rs. 2,000 for ASHA workers and Rs. 3,000 for ASHA facilitators – starting from July. Citing their work for the Covid-19 surveys in rural areas, Health Minister Rajesh Tope called the 65,000-plus ASHA workers of the state “a strong pillar of our health infrastructure.”

As of August 10, the ASHAs we spoke to hadn’t received their revised honorariums or incentives for July.

But they continue working. “We work tirelessly for our people,” says Tanuja. “May it be severe drought, heavy rains, hailstorms, or the coronavirus, in any situation we are the first to attend to people’s health. We are inspired by Savitribai Phule, who dedicated herself selflessly to help people during the outbreak of plague in 1897.”

Postscript: Osmanabad’s ASHA workers and facilitators supported the all-India strike on August 7-8 called by unions across the country. Besides long-pending demands such as regularisation of ASHAs as permanent workers, fair (and timely) pay, an increase in incentive rates and transportation facilities, they are insisting on safety gear, special training for Covid-19 work, regular testing for frontline workers and insurance during the period of the pandemic.

This article first appeared in the People’s Archive of Rural India.

Ira Deulgaonkar is a 2020 PARI intern; she is in the second year of a Bachelor’s degree course in Economics at the Symbiosis School of Economics, Pune.