Overworked and Underpaid ASHAs in Kashmir go Into Protest Mode

Ganderbal, Jammu and Kashmir: Nine months ago, Shaheena Wani (29) from Chountpati Waliwar in Lar tehsil of Ganderbal district joined duty as an Accredited Social Health Activist (ASHA) in her locality. She chose this as her first job to serve the community and to help her family. However, to date, she has only received her first month's honorarium (assured initiative) of Rs 2,000.

"I did not even get money for my uniform. I bought it myself and it cost me Rs 1,700. So far, my colleague and I have made 400 ABHA [Ayushman Bharat Health Account] cards, but we have not received a single penny," Wani tells 101Reporters. She was supposed to get Rs 10 for every card made.

Administering vital vaccinations, guiding maternal and child health initiatives, and providing essential nutrition counselling are some of the key work areas of ASHAs in the rural landscape of Jammu and Kashmir. They work primarily three days a week, unless there is an emergency. Despite their valuable contributions, these grassroots health workers grapple with the weight of financial insecurity as their meagre incentives fluctuate with the number of patients they attend to and the services they offer.

Apart from their honorariums, ASHAs get incentives for running government initiatives. Under the Janani Suraksha Yojana, they provide guidance to expectant mothers on antenatal care, birth preparedness and how to recognise danger signs during pregnancy. Following childbirth, they extend postnatal care for 42 days and initiate a two-year-long baby immunisation programme.

"Despite our efforts, we are provided only Rs 600 per patient for this extensive service. Moreover, we often encounter significant delays in receiving these payments. It mostly takes five to six months to obtain what we rightfully deserve," Rubeena Showkat, an ASHA with 16 years of service in Chountpati Waliwar, tells 101Reporters.

The ASHAs conduct non-communicable disease screenings for individuals aged 15 and above. "These screenings encompass full body assessments, diabetes tests, blood pressure checks and weight monitoring. They are conducted every Saturday at our centre. We are also tasked with maintaining the Comprehensive Basic Assessment of Care records, both online and offline. For these efforts, we are supposed to receive Rs 1,000, but payments are consistently delayed," she explains.

Similarly, the incentive of Rs 250 per child for initial immunisations has been delayed. "We have expressed our concerns through protests, and assurances were given to resolve the issue. Regrettably, upon checking the data, we discovered that not even 40% of the promised compensation had been provided

Articulating their concerns and advocating for prompt enforcement of the Minimum Wages Act, 1948, ASHAs from several regions of Kashmir gathered at the Press Enclave in Srinagar and held a large-scale protest on September 17. In a stern declaration, the ASHAs made it unequivocally clear that they would go on strike if their demands were not swiftly met.

They say instead of honorarium, they are requesting the government to provide them with a monthly salary of Rs 5,000. Even the sought amount is insufficient, considering the nature of their work in remote areas.

Meanwhile, Lar Block Medical Officer Dr Ishtiyak Naik tells 101Reporters that the policies made at the Central level are implemented for all ASHAs, and the government is actively addressing the issues at the Central level.

While claiming that the monthly honorariums are paid on time, Dr Naik admits that other incentives are currently pending. "When the budget allocations come in, the pending payments will be cleared," he says. About the delay in providing uniforms to ASHAs, he says funds are released once in a year for the purpose and that ASHAs would receive their uniforms at that time.

Dispelling myths at a difficult job

Chountpati Waliwar comes under Chunt Waliwar village, which is home to 901 families. According to the 2011 Census, Chunt Waliwar has a total population of 5,950, comprising 3,003 males and 2,947 females.

The village's literacy rate is lower (48.24%) than that of Jammu and Kashmir's overall literacy rate (67.16%). The male literacy rate stands at 58.20%, while the female literacy rate is 38.31%. Furthermore, Scheduled Tribes account for a majority (45.01%) of its population.

For ASHAs, going door-to-door motivating people about immunisation is an incredibly challenging task. Sometimes, people refuse to come out of their homes, and at times, they hesitate to give Aadhaar cards for generating ABHA IDs, fearing misuse.

"I vividly recall an incident during the peak of the COVID-19 pandemic when we tirelessly went from door to door for vaccination. Some people would even attack us, and tragically, a woman with pre-existing health issues passed away after receiving the vaccine. Her family unjustly blamed me, alleging that the vaccine was the cause of her death," Showkat says.

"There was a prevailing myth at that time that we were injecting viruses through vaccines. Once, I encountered a man who sternly warned me that if I ever visited his home, he would harm me with his axe. Despite enduring such challenges, the government has not paid adequate attention to our plight," laments Showkat, while collecting forms from the mothers of newborn babies at her centre.

Recalling an incident when a woman in the seventh month of her pregnancy had to be hospitalised late in the evening due to bleeding, Wani says, "We quickly shifted her to the first sub-district hospital in Lar and then to LD Hospital in Srinagar. After she gave birth to a baby girl, I returned home at 2 am in the ambulance, and the driver dropped me midway. I had to call my husband, who then borrowed a motorcycle to pick me up. 'For just Rs 2000, you go through so much struggle. Even a labourer earns more than you,' my husband used to tell me."

Wani is the designated ASHA of Parveena (20), who is three months pregnant. During her routine check-up, she warmly expresses: "It is Shaheena di who has been guiding me about antenatal care. These ASHAs are incredibly helpful. They dedicate their time to visit our homes and impart crucial knowledge about antenatal care and immunisation, ensuring the well-being of both mother and child."

Capacity Building Efforts

Last year, a two-day capacity-building workshop was organised at Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Soura, with an aim to minimise unnecessary interventions during childbirth, lowering the caesarean rate, and reducing the workload for doctors. A new cadre of nurse practitioners and midwives was established to provide comprehensive assistance to women during pregnancy, childbirth and postpartum stages.

Supported by the Government of India, the initiative was a collaborative effort between the Jammu and Kashmir National Health Mission, Postgraduate Institute of Medical Education and Research, Chandigarh, and the United Nations Population Fund, New Delhi.

"For getting trained as an ASHA for midwifery, all that is required is class 10 pass or seven years of experience in the field. However, the selection for the training lies with the higher authorities. Unfortunately, in Kashmir, no one from our region was chosen for this valuable training opportunity," Showkat notes, adding that her days of training had been in the range of five to 10 days. She suggests that training should continue in the village afterwards to facilitate continued learning.

In this regard, Dr Naik explains that they conduct workshops periodically and are actively working on providing adequate training to all ASHAs.

Meanwhile, Wani says ASHAs have repeatedly requested the Union Territory administration to provide them with tablets for official work since their phones struggle with the heavy online workload. "Our honorariums and incentives are not sufficient to purchase a smartphone," she says.

Highlighting the importance of door-to-door awareness campaigns, Sabreena Gul (32), a female multipurpose health worker at Chountpati Waliwar, says the unique local language complicates communication, making ASHAs indispensable for effective outreach.

Despite their efforts, ASHAs still face challenges in mobilising the community. "Today is the immunisation day, and people were informed yesterday to bring their children for immunisation. It is already noon, and no one has turned up yet," Gul says disappointingly.

(Fahim Mattoo and Sadaf Shabir are Kashmir-based freelance journalists and members of 101Reporters, a pan-India network of grassroots reporters.)