Health Leaders – Honouring India's Accredited Social Health Activists (ASHAs)

More than 10.4 lakh accredited female health workers in India have been honored at the 75th World Health Assembly for their essential role in connecting the community with the health system to ensure primary health care services [1]. ASHA is a Hindi term meaning hope. ASHA personnel do door-to-door visits in villages to raise public awareness about various health conditions. ASHA employees fulfil supervisory duties and have been involved in the contract tracing of suspected Covid-19 patients across all states by compiling extensive travel and contact histories. In the early months of the lockdown, they were involved in listing details of travel, contact individuals of every person entering the hamlet, particularly in the context of migrant returnees and travelers from overseas. However, the award has given hope for the ASHAs who were Underpaid and Underappreciated During Pandemic Era. Indispensability of ASHA health leaders have deeply entrenched during the global pandemic situation which amplified the demand for their service to tide over the precarious condition. Realizing their moral imperative towards the society, they have put their own life in peril towards safeguarding the humanity. The clueless situation has raised the prominence of preserving the workforce of medical care to tide over the condition. Given the current pandemic, ASHAs continue to serve society with minimal payments and social security. The unprecedented event requires much more than mere appreciation to end their social and financial hardship. The pandemic is not discriminatory in itself, but it affects ASHAs differently.

As per Ministry of Health and Family Welfare, “in India10.61 lakh accredited social health activist (ASHAs) is engaged in rural and urban areas under the National Health Mission (NHM)” [2]. The Government of India established the certified social health activist (ASHA) programme in 2006 with the purpose of connecting marginalized populations to the health-care system. ASHAs operate at the ground level to put any government health scheme into action. Their daily duties included checking on babies, pregnant women, and those who were at risk of disease. On a regular basis, they also distribute tablets such as iron deficiency tables. The current pandemic crisis has enlarged their job to keep an eye on covid-19 sighs among individuals and to spread preventive measures to the communities they visit [3]. Similarly, 2.6 million Anganwadi workers (AWWs), and an entire cadre of Auxiliary Nurse Midwives (ANMs) have been at the vanguard of the Covid-19 response system. For decades, the three groups of female community health workers have been working to improve primary health care outreach and community nutrition initiatives across the country. Despite the fact that their job is critical to India's health-care system, they are frequently underpaid and underappreciated. During the pandemic, all three cadres reported feeling alienated and unappreciated for the disproportionate weight they bear in India's war against Covid-19 without enough remuneration, personal safety, or state support. The unpaid, devalued, and invisible labour of India's community healthcare workforce was critical to the country's pandemic response.

Working within containment zones without proper facilities put ASHA workers' lives in jeopardy in numerous states. Several ASHA workers have died in Bihar, Madhya Pradesh, Delhi, Assam, and Jharkhand, either as a result of Covid-19 infection or misfortunes such as traffic accidents and tiredness while doing their healthcare tasks. The study states that the family members of the deceased Workers have undergone hard times in getting the Insurance benefits [4].

Considering the safety and social security of the health workers, Government of India has initiated insurance scheme for Health workers combating COVID-19 named “Pradhan Mantri Garib Kalyan Package (PMGKP)”. This insurance scheme has been introduced for all health workers including ASHAs for providing insurance cover of Rs. 50 lakhs for on-duty death relating to Covid – 19. The scheme is active with effect from 3rd March, 2020 and implemented through the Insurance policy from New India Assurance Company (NIACL). Nonetheless, States and other stakeholders have criticized that the processing of insurance claims is prolonged. Again, in order to overcome the issue, the government has delegated the power of processing the claims to the State Government, where District collector is empowered to certify the claim which is then approved and settled by the insurance company [5].

The 3As - ASHAs, AWWs, and ANMs are the groups consist of women community workers who work at grassroots level fall within the ambit of two ministries, i.e., the Ministry of Health and Family Welfare (MoHFW) and the Ministry of Women and Child Development (MoWCD) [10]. MoHFW has ascertained that ASHAs do not fall under the Code on Social Security and the Code of Wages, 2020, since they are volunteers envisaged to be community health service. Hence, they are entitled to task/activity-based incentives and cannot claim the benefit under social security schemes on par with the regular employees.

In this respect, ministry has requested the states to pay the incentive of Rs. 2000/- to ASHAs during COVID-19 Pandemic and additional incentive of Rs.1000/- per month for those ASHAs who are engaged in COVID-19 related work using the resources of “COVID-19 Health System Preparedness and Emergency Response Package” from January, 2020. Under the scheme, government has grated Rs. 1113.21 crore and Rs. 8147.28 crore to States/UTs as Grant-in-aid to state for facilitating the scheme. States/UTs were also asked to continue to pay other task-based incentives to ASHAs such as Janani Suraksha Yojana (JSY), Home Based Newborn Care (HBNC), etc., as per National/State norms during the course of this pandemic period as per the activities undertaken by them.

The MoHFW has reiterated the following benefits for ASHA workers under the schemes-

(1) Pradhan Mantri Jeevan JyotiBeemaYojana (PMJJBY) - provides the benefit of Rs 2,00,000 for death of the insured, and the premium of Rs.330 is contributed by Government of India.

(2) Pradhan Mantri Suraksha BeemaYojana – provides 2,00,000 for accidental death or permanent disability and 1,00,000 for partial disability for which the Government contributes Rs.12 as annual premium

(3) (PMSBY) and Pradhan MantriShram Yogi MaanDhan (PM-SYM) – provides pension of Rs. 3000 on monthly basis on reaching the age of 60 Years. The premium contribution is shared by for government and beneficiary equally.

According to Ministry of Health and Family Welfare, till March, 2021, 8,78,071 community workers group including ASHAs have received additional COVID-19 and 43 claims have been paid for to ASHAs under Pradhan MantriGaribKalyan (PMGK) Package till June, 2021. Notably, as per the record of MoHFW no delay has been reported in payment of benefits by States and UTs [6].

Issues and concerns

Concerns vis-à-vis safety and welfare of health workers have been raised by various groups. Hundreds of thousands of community health workers (ASHA workers) went on strike in August to demand proper personal protective equipment (PPE), higher pay, and reasonable and favourable working conditions. There has been a lot of conflicting information on total number of Covid related deaths. According to a BBC News survey, the government lacks consolidated data and does not keep occupation-specific census and death statistics of ASHAs [7].

Conclusion

Health-care employees are the foundation of every health-care system. To secure the family and their future, social support to spouses and kin is the need of the hour. For instance, the state government of west Bengal has galvanized the state machinery and mobilized all resources at its disposal to combat the situation arising due to outbreak of covid – 19. It is evident from the recently designed special compassionate appointment scheme providing appointment to the kin of essential and frontline workers died due to covid - 19.

The scheme is based on two attributes – (1) death due to covid-19 (2) permanent incapacitation due to covid-19. As the title of the scheme indicates, it is really special, since it encompasses not only the permanent government servants but also employees working on temporary basis. According to para 2(A) of the scheme, apart from state government employees, rural and urban local bodies, public undertakings, Statutory Bodies or any Grant-in-Aid institutions were also given benefit. Para 2(B) take account of all frontline workers like ASHA workers, Anganwadi workers, civic police volunteers, multipurpose health workers, contractual and part-time medical personnel including nurses, sanitary workers, people engaged in laundry diet and drug management. The need of the hour is for each state to develop a particular system to solve the current situation, similar to West Bengal's compassionate appointment scheme, to better address the challenges encountered by ASHA workers. In this regard, it is the Central government's responsibility to offer adequate instruction to the state government and its agencies.

REFERENCES

[1] World Health Organisation (WHO), https://www.who.int/india/india-asha-workers

[2] Amine Souadka (2020), ‘COVID-19 and Healthcare workers families: behind the scenes of frontline response, 23 Lancent, https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30117-6/fulltext.

[3] Anuradha Raman (2020), ‘At the Forefront of India’s Healthcare System, ASHA Workers Soldier on – Unprotected and Poorly Paid’ The Hindu (New Delhi, 04 July 2020) https://www.thehindu.com/society/at-the-forefront-of-indias-healthcare-system-asha-workers-soldier-on-unprotected-and-poorly-paid/article31979010.ece, 23 September 2020.

[4] Bhanupriya Rao & Sreya Dutta Chowdhury (2020), Female Frontline Community Healthcare Workforce in India during COVID-19, Behonbox.

[5] Indian Medical Association, https://www.ima-india.org/ima/.

[6] Ministry of Health and Family Welfare, Welfare of Asha Workers during Covid 19 Pandemic 27 July 2021, https://pib.gov.in/PressReleasePage.aspx?PRID=1739461

[7] Jugal Purohit (2021), Covid-19: India health workers' families fight for compensation, BBC World Services, Delhi, https://www.bbc.com/news/world-asia-india-58621933.

Author Chemmalar. S is Researcher, SRM School of Law, SRM Institute of Science and Technology, Chennai