Foot soldiers in India's battle to improve public health

BAGDOLI, India — A health worker was making her daily rounds in a village in the northern Indian state of Rajasthan when the husband of ...


BAGDOLI, India — A health worker was making her daily rounds in a village in the northern Indian state of Rajasthan when the husband of a woman suffering from nagging labor rushed towards her.

For months, the health worker, Bhanwar Bai Jadoun, had advised the woman to give birth in the hospital. But the woman’s mother-in-law insisted on giving birth at home with the help of a local midwife.

Now complications had set in. Mrs. Jadoun suggested taking the woman urgently to a hospital 10 miles from the village, Bagdoli; she would notify the doctors there. An auto rickshaw was arranged. Both mother and baby were saved.

“When people see me every day, they know they can trust me,” Ms Jadoun said. “They see me as their guide to healthy living.”

For the past two decades, a government program has provided basic home health care across the vast land of India. The core of the project is an army of over a million female health workers, who roam rugged terrain and dense jungles to treat some of India’s most vulnerable women and children, for low pay. and sometimes to the detriment of their own lives.

These women are neither doctors nor nurses, but they are being trained to bridge the healthcare gap in places, both rural and urban, where such services were previously non-existent. For years, their job has been to encourage vaccination and family planning, as well as to treat basic illnesses.

“They have become the backbone of primary health care services in this country,” said Ritu Priya Mehrotra, professor of community health at Jawaharlal Nehru University in New Delhi.

During the deadly waves of the coronavirus pandemic, these women – known by the acronym ASHA for Accredited Social Health Activist – played a crucial role in saving the lives of hundreds of thousands of coronavirus patients, officials from the Indian Ministry of Health, helping in early detection of cases and disseminating prevention information. They have been instrumental in tackling vaccine hesitancy and helped India run one of the largest vaccination campaigns in the world.

Now, with the pandemic workload beginning to slow, these women, who say their work spans more than 14 hours a day and sometimes seven days a week, are protesting across the country over their meager wages.

Regional governments pay health workers around $40 a month, plus incentives. For example, there is a $4 bonus for each hospital birth they facilitate and $1.50 for each fully vaccinated child under one year old.

They want a monthly salary of around $150, with incentives.

“Even when the mortar shells land in the villages, we work,” said Bimla Devi, who lives near the India-Pakistan border in Jammu, where troops often exchange gunfire. “When people are hurt, you can’t tell them that my job is only to take care of women: you are going to help.”

Dozens of workers have died during the pandemic after being exposed to the coronavirus, in part because they lacked protective gear. A study of three Indian states by Oxfam public health researchers in 2020 found that at least 25% of health workers received no masks and only 62% received gloves.

A worker, Geeta Devi, contracted Covid in a hospital, where she had accompanied a pregnant woman to give birth in the northern state of Himachal Pradesh. After she fell ill, her husband struggled to find her a bed.

“She died helping people, not taking care of herself,” said her husband, Rajvansh Singh.

Despite the risks, health workers across the country have been monitoring coronavirus patients, providing medicine kits, isolating patients and sometimes delivering food to people in quarantine. Their most critical roles were to ensure continued access to essential health services when hospitals ran out of beds and to encourage vaccination.

Several women said they were beaten with sticks by angry villagers, who chased them away after rumors on social media that the Covid vaccine had killed people or rendered them infertile.

“People were reading lies on social media, and we were motivating them to get vaccinated,” said Seema Kanwar, who has been doing the job since 2006. “We told them we took the vaccine, and we are not dead, how are you? ”

India’s federal health ministry did not respond to emails seeking comment on the health workers’ deaths, the availability of protective equipment and their demands for higher salaries. Prime Minister Narendra Modi has often praised health workers for their efforts to implement government health plans at the local level.

Although the pandemic has been the focus of concern for the past two years, workers’ mandate has always been broader than that, and now their attention is returning to general health issues affecting women and children.

Public health infrastructure remains grossly underfunded in India, with a shortage of more than 600,000 doctors and two million nurses, according to a report by the Center for Disease Dynamics, Economics & Policy, a Washington-based research group and New Delhi.

India, a country of 1.4 billion people, has a poor health care record, especially for women and children. Malnutrition is widespread; infant and maternal mortality rates are high. The causes include poverty, lack of access to doctors in rural areas, resistance to modern medicine and a deep-rooted denial of women’s rights.

But health authorities have recently made remarkable progress in reducing death rates during childbirth. In March, the Federal Ministry of Health said the maternal mortality rate had risen from 122 to 103 deaths per 100,000 births from 2015 to 2019. The United Nations target of bringing it down to 70 by 2030 now seems at hand.

As part of this effort, India introduced a health plan in 2005 which, among other things, introduced incentives to give birth in a hospital.

But given both the difficulty of getting the word out in remote areas and widespread distrust of government programs, success would have been impossible without health workers gaining the trust of their communities, say experts.

Every morning, Ms. Jadoun, a history graduate, leaves her home, sometimes covering her face with her sari when the men are around, a mark of respect in rural areas. It serves an area with a population in the thousands.

In one home, she counseled a woman on childbirth preparation; at another, she wrote down the name of a woman who had just learned that she was pregnant. She will watch over her, give her iron tablets and register her name at a nearby public hospital.

“We are not only fighting superstition, but also traditional practices,” Ms Jadoun said. “But when I look at zero deaths of women in childbirth and healthy people around, I’m proud of what we’re doing.”

Anant Bhan, a public health researcher at Melaka Manipal Medical College in southern India, said the advantage of community-dwelling health workers has helped India address huge gaps in the delivery of health services in the most remote corners of the country.

“The challenge is that ASHA workers are still seen as volunteers and expected to do a lot of work by the government, without being paid enough,” he said.

On a recent afternoon, Sunita Jain, another health worker from Rajasthan, walked through a narrow lane of mud and brick houses in a village there, Kolara. She was visiting Diksha Sharma, whose due date was approaching.

Ms Sharma said her husband wanted her to deliver her second child at a private hospital dozens of miles away. Ms Jain sought to convince her that giving birth at a nearby free public hospital was safe.

“Do you want to take care of me?” Mrs. Sharma asked Mrs. Jain. Her mother-in-law listened attentively to the conversation. (In rural India, it is often the mothers-in-law who decide on childbirth issues.)

“Not only will we take care of you, but I will go with you to the hospital and stay there,” Ms Jain said. “Believe me, everything will be fine, like last time.”

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