India’s health workers are underpaid and overworked

The women who liaise between village residents and the public health system are on the brink of collapse, working long hours for little pay to manage Covid-19 on top of their regular duties.

Mandakini Kodak was three months late for her checkup. When she finally made it to the doctor, his suggestions were the same as the year before: “Don’t overstress, eat on time and only do what is possible.” His warnings were serious.

Kodak has high blood pressure or hypertension and constantly feels tired, despite taking medication. “I had no time to go to the doctor and occasionally skipped medicines because of the workload,” she says. When she finally consulted the doctor in 2020, he diagnosed an alarming rise in her hypertension and immediately doubled the dose of her medication. “It’s surreal. I chose to become a healthcare worker because I love helping people. Never did I think this job [would bring] medical ailments and so much stress.”

2 June 2021: Asha workers Mandakini Kodak and Rekha Dorugade try to convince a hesitant resident to be vaccinated against Covid-19. Vaccine hesitancy has emerged as a significant challenge for Ashas.

Kodak is an accredited social health activist (Asha), the foot soldiers of India’s rural healthcare system. Appointed for every 1 000 people, Asha workers are village women who act as the point of contact between villagers and primary public healthcare.  

As per the Indian health ministry’s plan for containing Covid-19, Ashas, along with a number of other assigned personnel, have been tasked with containing and managing the Covid-19 pandemic.  

“Every day, I check the oxygen levels and temperature of the community members,” Kodak says. She has to find suspected Covid-19 cases, trace people who have been in contact with them, monitor them, ensure people complete the quarantine period, promote Covid-19 awareness and submit these details every day. She has been doing this without a break for more than 400 days now.  

2 June 2021: Negating Covid-19 misinformation has increased the workload of Ashas. Bharti Kamble teaches her son Shivraj about the rampant spread of misinformation and how to check the facts.

Kodak, a resident of Pernoli village in western India’s Maharashtra state, has had many bad days. “For several months now, an old woman stands with a stick at her house. That’s her way of welcoming [me] and suggesting [she will not be convinced] to get vaccinated,” she says. She recounts a recent case where a villager refused to say if he had Covid-19 symptoms and two days later tested positive. It took Kodak several hours to contact trace 2 265 residents to ensure people got tested. “People fear Covid ostracism and verbally abuse us for doing the job.” 

Kodak is one among 970 000 Ashas surveying 600 000 Indian villages to contain Covid-19. “I [have been] working since 2009, and yet we aren’t recognised as full-time workers. There’s no medical leave. So, if we delay the day’s work even by an hour, the sanctioned payment is cut,” she says. Ashas, who are considered volunteers, receive “performance-based incentives” and average a monthly income of between R580 and R760 in Maharashtra. 

Difficult working conditions

Asha Bharti Kamble, 34, underwent a hysterectomy in February 2020. It cost her R7 620, the equivalent of her salary for a year. “Within 20 days, I was asked to [go back on] duty. [But] the doctor [had] advised complete bed rest for three months,” she says. Kamble didn’t think twice about her health. “No matter what happens, an Asha will always save her community.” 

As Covid-19 started spreading across India in March 2020, Kamble, like many Ashas, didn’t receive any training. “There was once a video lecture, but that … happened when the cases increased rapidly.” She was not given an N95 mask, hand sanitiser or gloves, forcing her to spend her meagre wages on personal protective equipment. As part of her Covid-19 duty, officials “pressurised” her to begin surveying as early as 7am and to keep going until 4pm. “I wouldn’t get to eat on time.” 

2 June 2021: Ashas are tasked with more than 70 responsibilities, including providing medication for common ailments such as coughs and colds. In remote villages, Ashas stock these essential medicines at home.

One evening, she collapsed. “The doctors had put intravenous drips [electrolytes and a saline solution] and suggested bed rest,” she says. But her duty and the workload didn’t permit it. She collapsed twice within a month, prompting her husband to talk to the Covid-19 officials. “He said, ‘No matter what, Bharti won’t join the duty before 9am,’” she remembers. 

A diabetic with hypertension, Kamble has lost count of the times she has spoken to senior officials about her medical condition. “All they suggested was to adjust,” she says. But this adjustment has come at a cost. Like Kodak, Kamble’s medicine doses for both conditions were doubled within two months of starting Covid-19 duty.

“Even at midnight, the health officials call us for work,” she says. “The medicines which I require aren’t available in the public health centres. They cost me [R670] monthly.” Kamble struggles to raise this money. “Our salary has been delayed for four months now.” 

21 June 2021: No rest and stress exacerbated Asha Mangal Kamble’s diabetes to the point where it was out of control. She had to increase her medication substantially, which the public healthcare system does not cover.

Her efforts helped contain Covid-19 in the remote village of Bolakewadi in Maharashtra’s Kolhapur district for 15 months. More than half the 701 village residents migrate to cities for work. Only in June this year did two of them test positive. When the workload gets too much, she talks to fellow Ashas, all of whom are experiencing similar problems. “The government announced an insurance of [R953 384] for healthcare workers and patted their backs. Only God knows where that insurance is as we weren’t even made to sign any policy documents,” she says. 

For doing Covid-19 duty, the government announced pay of R6 a day for Ashas. “Several Ashas haven’t even received this pay for over 14 months now,” says Kodak. 

More than 70 000 Ashas across Maharashtra went on strike from 15 June, demanding the status of full-time workers, salary increases, reimbursement for Covid-19 treatment and more. It was called off after nine days when the government announced an increase of R190 a month and R95 extra a month for Covid-19 duty, starting 1 July. 

Devastated public healthcare

Mangal Kamble, 44, would feel dizzy, sweat and often experience blurred vision while on duty as an Asha. “I would drink some water, sit for five minutes and move to the next house,” she says. But her symptoms were a sign of something serious, which she found out two months later. “My diabetes was out of control and the doctor prescribed … 100mg [of] medicine, straight up from 2mg,” she says. “What aggravated my type 2 diabetes was continuous pressure from senior officials, no rest and stress.”

She has to travel 15km from her remote village of Sarambalwadi to the town of Gadhinglaj to buy these medicines, spending about R670 monthly. “It’s unaffordable. The [public health centre] officials said they don’t keep medicines of a higher dose.” This means Kamble cannot access government support.

21 June 2021: More than 70 000 Ashas from across Maharashtra state on strike. They called off the strike, which started on 15 June, after nine days when the government agreed to meet some of their demands.

Poor public health infrastructure and the exploitation of Ashas make her days stressful. “With several public healthcare facilities converted to Covid centres, the pregnancies in public hospitals are shut and poor families are forced to rush to private, unaffordable hospitals.”

In March, a woman from the area urgently needed to be hospitalised. Kamble went to seven hospitals before the woman was admitted. “First, I ran to two public hospitals, both of which denied admission because of Covid cases.” Next, she travelled another 50km going to five private hospitals. “At 4am, I managed to find a private hospital. Both the woman and baby are safe,” she says. For ensuring safer pregnancies and healthy births in public hospitals, Ashas are paid an incentive. “I didn’t get a single rupee because it was a private hospital. But I spent an entire day, and the government should know how Ashas are saving lives.”

Kamble now doubles as a farm labourer or takes out loans at exorbitant interest rates to buy her medicines. “I am tired of requesting the authorities. Often my family members ask me why I keep doing this job [if they don’t] even care if I am alive or dead.”

‘Exploitation and mental stress’

Netradipa Patil, an Asha and the leader of more than 3 000 Ashas from Kolhapur’s Shirol region, was on the brink of collapse from exhaustion. “Never did I think I would fall ill for six months,” she says. How did she get into this situation? “It was a viral infection. Soon, my calcium, protein, sodium, vitamins and at least five other parameters deteriorated.” 

It started in August 2019, when floods ravaged the villages of western Maharashtra. Just as Ashas were able to take a break from flood relief, Covid-19 hit the villages. “The government kept changing the Covid survey formats, which meant redoing all the work. Even today, the survey hasn’t stopped,” she says. Often village officials and higher-ups blame Ashas for the rising Covid-19 cases and deaths. India reported more than 30 million Covid-19 cases and almost 400 000 deaths by 2 July.

21 June 2021: On 21st June, over 2500 ASHAs protested in Maharashtra’s Kolhapur district. An ASHA dressed as Goddess Durga as part of the protest.

Without adequate safety gear, surveying became difficult and dangerous. “Not everyone has big houses to isolate themselves. What if we carry the virus?” Patil’s health kept worsening and in October 2020, she was hospitalised for a week. After being discharged, she became infected with chikungunya, a mosquito-borne virus. “Three people would help me get up from bed. It was that painful,” she says. 

Patil sought treatment at private and public hospitals, spending her own money. “Several testing facilities aren’t available in public hospitals. Unfortunately, the government doesn’t want to understand this and blames us for seeking treatment in the private hospital.” 

She started feeling better in April, but her workload kept increasing as the second wave of the pandemic devastated India. “Ashas need the help of psychologists. It doesn’t matter to the officials if we’ve eaten or not. All they want is records and data to be completed on time,” she says. 

5 June 2021: Ashas Netradipa Patil and Maya Patil weigh a newborn baby.

Patil receives several calls from Ashas every day. “Almost everyone talks of either exploitation or mental stress.” She has written more than 100 letters to officials, from the local level all the way to the central authorities, demanding better working conditions.  

Kodak wants Ashas to someday get the pay and respect they deserve and for which she has been fighting for a decade. But after protesting several times, even travelling the 1 750km to India’s capital of New Delhi, she now thinks hope is futile. “Ironically, the word asha means hope [in Hindi], and now we are left with no hope.”

Kodak became an Asha because she wanted to help people. “And I have done that all my life,” she says. Ashas save countless lives in remote villages despite the odds stacked against them, and they deserve empathy, she adds. They also deserve proper pay and working conditions.

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