Rekha Dorugade is used to receiving anxious calls and messages any time of day or night. On 21 February, it came at 11pm and simply said “she is about to give birth”. Despite having a fractured leg and two broken fingers, Dorugade took her torch, first aid box, a bed sheet and scissors and dialled the number for the public ambulance.
Dorugade, from Pernoli village in Maharashtra state’s Kolhapur district, is an accredited social health activist (Asha) – a woman community health worker who provides basic nursing care and assistance to rural residents. One is appointed for every 1 000 people to act as a liaison between rural communities and the public healthcare system. Tasked with educating villagers on giving birth in hospital, vaccinations for children and family planning, among others, they form the backbone of rural healthcare in India.
Dorugade’s 5km-long journey was dangerous in the dark, but any delay could cost the pregnant mother and her unborn child. “It was so scary. You will fall if you make one mistake,” she said.
She realised the mother, Ranjana Jhore, 22, needed to be hospitalised. The nearest birthing centre was 12km away. Reaching it meant descending the steep Dhangarwada hill. Helpers from the village used their traditional method, a wooden palanquin, to carry Jhore and Dorugade and a doctor met them halfway.
“That sight was haunting,” said Dorugade. “Wherever we pointed the torch, all we could see was blood. Immediately, the doctor clamped and cut the umbilical cord and rushed them to the hospital.”
Mother and child were discharged after four days. “Only then did I breathe a sigh of relief,” said Dorugade. But she didn’t anticipate what happened next.
While Jhore’s family was thankful, Dorugade’s seniors weren’t impressed. “They ordered an inquiry into what led to this [childbirth en route]. They yelled at me, asking why I didn’t ask the woman to stay near the hospital,” she said. But she had, eight days prior to the birth. “Ranjana said there’s still time left and denied my multiple requests.”
Dorugade’s account of the incident was dismissed by the district’s health department. “They told me I should have given this message to Ranjana in writing. After this, they began auditing all my written records and work.
“This behaviour was so humiliating and insulting. None of them would have risked their life to trek with a broken foot. The health department doesn’t see how we work in such circumstances. Neither did they enquire If I was doing okay,” said Dorugade, who has helped thousands of people in the 13 years she has been an Asha.
Overburdened and underappreciated
Dorugade is not alone in feeling this way. More than one million Ashas across India are overburdened by 74 healthcare tasks they have to perform, including providing pre- and postnatal care, counselling women on birth preparedness and providing contraceptives and medicines for common health ailments. Their payment is based on performance.
“In Maharashtra, Ashas average a monthly income of 3 500 to 4 000 Indian rupees,” said Netradipa Patil, the union leader for over 3 000 Ashas in the Kolhapur district. This amounts to between R684 and R782 a month. The Ashas were also promised a Covid-19 pay of R196 a month, but many “haven’t received this pay for several months”, she added.
Ashas were first appointed in 18 states in 2006 under India’s former National Rural Health Mission. Within a few years their use spread across the country, and they have spent all their time since building bonds with their communities and earning their trust. They have also helped lower the maternal mortality rate from 254 deaths per 100 000 live births in 2006 to 113 by 2018.
In July 2021, as western Maharashtra was devastated by the second flood in three years, Rupali Patil, an Asha from Kolhapur’s Tiravade village, found the floodwater reaching the outskirts of her remote village of 1 723 residents.
Patil knew Vinita Desai was to give birth within days. In the third week of July, within two hours of visiting Desai, she got a call informing her that labour pains had begun. She took Desai to the nearby Kadgaon Primary Health Centre.
“It didn’t have a facility for caesareans and she was referred to the Gargoti Rural Hospital.” Patil arranged for an ambulance to take Desai to the hospital, which is 17km away, and accompanied her. However, with rising floodwaters, the last stretch of the track had to be done by boat. “Upon reaching the hospital, we found that it was overburdened with Covid patients and she was referred to a private hospital 40km away.”
Finally, Desai could get the surgery. “Looking at the heavy rains and floods, everyone thought Vinita won’t survive. But people trust us, how can we let them down?” said Patil. “What people need during such tough times is someone to talk to. So, I kept telling her that all the resources are in place and we can’t lose hope.”
Both Desai and her son survived because Patil did everything right before, during and after the birth. She maintained field notes, consistently visited the family and regularly did follow-ups. “Community members call us even in the middle of the night and we never deny them service,” she said proudly.
A vital service
For its rural population of 833 million people India has 810 district hospitals, 155 404 sub-centres or peripheral outposts, 24 918 public health centres and 5 183 community health centres.
“Without Ashas, we doctors can’t work in the community,” said Varsha Lokhande, a doctor at Kolhapur’s Ghalwad sub-centre. “Ashas are the only healthcare workers who know the medical history of every family in their community.”
Through monthly camps, Ashas look after pregnant women by monitoring their blood pressure, doing blood screening and measuring other important milestones. They also help identify the women with high-risk pregnancies who need referral to public hospitals with better facilities, and arrange for them to get there. “Without Ashas none of this can be done,” said Lokhande.
A case in point is Sonali Mane, whose pregnancy was going well until the very last day. She had just been diagnosed with dengue fever, a viral disease spread by mosquitoes, when her labour pains started. According to Pornima Chudmunge, 28, an Asha from Kolhapur’s Shirol region, the local hospital asked her to get Mane transferred to a better-equipped facility as the case was complicated.
This was during the peak of the lockdown in July 2020 when travelling was severely restricted. Chudmunge rushed Mane to a public hospital in Sangli, 15km away. She made her way through several departments, collected reports and explained the situation to a senior doctor.
The doctor didn’t think both mother and child could be saved and asked Chudmunge to sign legal documents indemnifying the hospital. She was taken aback. “I was worried, but being scared doesn’t help,” she said.
Chudmunge completed the paperwork and called her seniors, including nurses as well as a retired doctor who kept advising her on how to help Mane. “I kept telling her that she’s strong and we will face this challenge.”
Meanwhile, in a hospital overflowing with Covid cases, all Chudmunge could see were patients gasping for oxygen. “During that time, it was important to save the patient. I didn’t think about Covid.”
Mane gave birth to a girl the next day and Chudmunge stayed with her throughout the next 72 hours, which were critical. “I had decided that I won’t move from the hospital till they were out of danger. I’ve handled several pregnancy cases but have never seen such a challenging case.
“Every Asha keeps finding her way through such onerous experiences. But the government only pays us after we protest. How much should we protest?” asked Chudmunge.
While Ashas remain the biggest source of healthcare support for their rural communities, they have been left without hope as their strikes over the years for better pay and benefits have not delivered results. “Coincidentally, Asha means hope, which we’ve lost now,” said Chudmunge.