MacroScan - Public Health on The Cheap

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.