One
of the more depressing features of government policy
in the social sectors in India is the extent to which
it relies on the unpaid or underpaid labour of women.
This was evident in the functioning of the Sarva Shiksha
Abhiyan in many states, as a parallel system of “Education
Centres” (rather than proper schools) was set up using
local women with eight years of schooling to teach children
for a paltry “remuneration”, rather than employing trained
teachers at regular wages. Similarly, the Integrated
Child Development Scheme operates on the basis of very
poorly paid anganwadi workers and helpers.
While these women perform essential and demanding tasks
that typically amount to full-time work, they are not
given the status of regular government employees. And
because what they receive as payment is so low that
it would contravene Minimum Wage Laws in many states,
it is described as “honorarium” rather than wage.
More recently, this tendency has been taken to its logical
conclusion. One of the flagship schemes of the UPA government
– the National Rural Health Mission (NHRM) – relies
almost totally on unpaid female labour. Indeed, the
lack of remuneration for the Accredited Social Health
Activists (ASHAs) who form the backbone of the scheme,
is part of its very design.
India is among the worst performing countries in the
world when it comes to government expenditure on health.
In 2004, such spending amounted to only 0.9 per cent
of GDP. Only four or five countries in the world had
lower ratios than this. The UPA government had promised
to increase this ratio to 3 per cent of GDP within five
years, but four years on, it is still only around 1
per cent!
However, the government did at least recognise the pressing
need to improve health conditions when it launched the
NHRM. Its stated goal is nothing if not ambitious: to
provide effective health care to the entire rural population
in the country, with special focus on the 18 states
that have weak public health indicators. Commentators
have pointed out that despite being presented as entirely
new flagship programme, the NRHM is essentially an amalgam
of already existing schemes and programmes. Most of
its key components, including the reliance on ASHAs,
have been tried before with varying degrees of success.
These elements include: the provision of a health activist
(ASHA) in each village; a village health plan prepared
through a local team headed by the panchayat representative;
strengthening of the rural hospital for effective curative
care and made measurable through Indian Public Health
Standards (IPHS), and accountable to the community;
and local integration of the different programmes and
funds of the Health & Family Welfare Department.
The most significant element of the NRHM is therefore
the ASHA, who is to provide the link between the community
and the government health system, and become the first
port of call for any health-related matters, especially
for less privileged groups. The Mission statement makes
that clear: “ASHA will be a health activist in the community
who will create awareness on health and its social determinants
and mobilise the community towards local health planning
and increased utilisation and accountability of the
existing health services. She would be a promoter of
good health practices. She will also provide a minimum
package of curative care as appropriate and feasible
for that level and make timely referrals.”
Does this already sound like a lot of work? But there
is more, for the NRHM explicitly requires ASHAs to do
many more things. Here is a brief list of all the activities
she is required to undertake:
-
create awareness and provide information to the
community on determinants of health such as nutrition,
basic sanitation and hygiene, healthy living and
working conditions, information on existing health
services and the need for timely utilization of
health and family welfare services;
-
counsel women on birth preparedness, importance
of safe delivery, breastfeeding and complementary
feeding, immunisation, contraception and prevention
of common infections (including reproductive tract
infections and sexually transmitted diseases) and
care of young children;
-
mobilise
the community and facilitate local people’s access
to health and related services provided by the government
at the local level, including immunisation, antenatal
and post-natal check-ups, ICDS, sanitation, etc;
-
arrange to escort pregnant women and children requiring
treatment and/or admission to the nearest pre-identified
health facility, which could be the Primary Health
Centre or the First Referral Unit;
-
provide primary medical care for minor ailments
such as diarrhoea, fevers, and first aid for minor
injuries;
-
be
a provider of Directly Observed Treatment Short-course
(DOTS) under Revised National Tuberculosis Control
Programme;
-
act
as a depot holder for essential health provisions
being made available to every habitation like Oral
Rehydration Therapy, iron Folic Acid tablets, chloroquine
for treating malaria, Disposable Delivery Kits,
oral contraceptive pills and condoms, etc;
-
manage
and allocate to members of the community the contents
of the Drug Kit supposedly provided to each ASHA;
-
inform the health authorities at the Primary Health
Centre or Sub-Centre about the births and deaths
in her village and any unusual health problems or
outbreak of disease in the community;
-
promote the construction of household toilets under
the Total Sanitation Campaign;
-
work with the Village Health and Sanitation Committee
of the Gram Panchayat to develop a comprehensive
village health plan.
Just
in case these tasks are not enough to keep the ASHA
occupied, the NRHM website helpfully suggests that “States
can explore the possibility of graded training to her
for providing newborn care and management of a range
of common ailments, particularly childhood illnesses”!
All these myriad tasks are to be performed by a local
woman who is to serve one village or population of one
thousand. The minimum qualification has been set at
eight years of completed schooling. This rigid requirement
has been placed even though there are several parts
of the country, especially in tribal and underdeveloped
areas that need such intervention the most, where there
are no literate women, much less women who have completed
elementary school.
Once chosen, the ASHA receives a total of 23 days of
training in separate modules, before being sent back
to fulfil her responsibilities. It is hard to imagine
how a mere few weeks of “training” in typical government
format can create all these capacities, especially when
the ASHA is also expected to diagnose and treat minor
ailments and recognise more serious illnesses.
And, having been thus chosen and trained, and then made
to perform all these complex and demanding tasks, what
is her remuneration? Amazingly, nothing at all! The
NRHM envisages that the “ASHA would be an honorary volunteer
and would not receive any salary or honorarium. Her
work would be so tailored that it does not interfere
with her normal livelihood.”
There is some grudging acceptance that ASHAs can be
compensated for the period they spend in training, but
only at the venue of the training and by day of attendance.
Any other remuneration can only come in the form of
the monetary incentives that are given as part of specific
programmes such as immunisation. Some state governments
have instituted payments to the ASHA, but in no case
do they exceed Rs 1000 per month. And usually the ASHAs
get much less, only around Rs 500 per month at most.
Yet in most cases, fulfilling all their responsibilities
would require the ASHAs to work for more than eight
hours a day as well as at odd times, given the unexpected
nature of sickness, deliveries, etc. All this is supposed
to be done out of a sense of idealism and community
feeling, trading on the time-worn stereotype of caring
woman who serve their families and communities selflessly
without any thought of return.
It is appalling to think that such a major and massive
programme could be designed and launched by explicitly
relying on the unpaid labour of so many women – already
nearly 500,000 ASHAs have been recruited, and now there
is talk of launching an Urban Health Mission with USHAs.
The bureaucrats who administer this programme are only
too happy to be the beneficiaries of periodic Pay Commission
awards that allow their own salaries to rise faster
than inflation. But when it comes to ensuring such essential
health services to the people, the women who bear almost
the entire responsibility for delivery are to be deprived
of minimally adequate remuneration. This combination
of cynicism and miserliness does not augur well for
the success of the programme.
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