The Unsung Heroes Of India’s Primary Healthcare The Anganwadi Workers And ASHAs

New Delhi: For years, lakhs of women community health workers – the Anganwadi workers and the Accredited Social Health Activists who are popularly known as ASHAs have been working on the frontlines providing basic healthcare including essential immunisation and nutrition to the country’s vast rural population. According to experts, the positive effects of the work done by these women is evident from the declining mortality among infants, children and new mothers in the country. UNICEF (United Nations International Children’s Emergency Fund) calls them instrumental to child development for the role they play in fighting malnutrition. However, these women feel that they remain largely unseen, unheard and unrecognised by others including the government. NDTV spoke to experts, Anganwadi workers (AWW) and ASHAs from various parts of the country to cheer their work, understand the challenges they face, on a daily basis and to celebrate this army of women who have become the backbone of the country’s healthcare infrastructure.

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An ASHA worker during a door-to-door survey on the health of families in the village

Who Are Anganwadi Workers And ASHAs?

Anganwadi workers are women volunteers providing services under the Integrated Child Development Services (ICDS) programme started by the Ministry of Women and Child Development (MWCD) on October 2, 1975, in a bid to tackle malnutrition among all pregnant women, lactating mothers and children in the age group 0-6 years. There are over 25 lakh Anganwadi Workers and helpers in the country. The work done by them includes providing supplementary nutrition, nutrition and health education, health check-ups, immunisation and pre-school informal education to children.

ASHAs are the grassroot health workers assisting the Ministry of Health and Family Welfare (MoHFW) in delivering primary healthcare, particularly for women and children, in both rural and urban areas since 2005. There are over 10 lakh ASHA workers in the country. The range of services provided by ASHAs include identifying and registering new pregnancies, births and deaths, educating new mothers and their families about breastfeeding, raising awareness about health and nutrition-related government programmes, distributing iron tablets, checking on immunisation schedules of babies and pregnant women, escorting pregnant women for institutional delivery, undertaking periodic checks on tuberculosis (TB) patient, supporting health service delivery through home visits, first-aid and maintaining data and participating in implementing the community-level health programmes.

Acknowledging the role of these community workers, Biju Prabhakar, Anganwadi State Nodal Officer, Government of Kerala said,

In rural areas of Kerala, community health workers are doing well. The crucial role played by them in child development is much appreciated in the community. Their silent work in bringing about a social change in various areas have resulted in the progress of a society. They are truly unsung heroes along with ASHA workers. We should always be thankful to them for their noble service.

He further said that almost 114 Anganwadi centres were destroyed by the flood that hit the state in 2018 but because of their dedication towards child welfare, they continued performing their duties via make-shift Angawadi centres for few months.

ASHA workers play a critical role in delivering healthcare to children in rural areas

In the state of Bihar, along with Anganwadi workers and ASHA workers, there is another army of women called “Jeevika Didi” who are playing an important role in educating families and young women about nutrition and health. Jeevika is Bihar’s rural livelihood promotion programme run by state’s government Rural Development Department. It creates women Self Help Groups (SHGs) to help them learn skills and get financial assistance for starting their own small enterprises. These women also assist the state government in training women in villages about various aspects of nutrition in order to fight malnutrition, which is rampant in the state, said Soumya, Jeevika programme manager. She further said,

They help households understand the importance of the first 1,000 days of a child’s life. Their contribution is important in changing behaviours. During the lockdown, these women contributed in the fight against COVID-19 by working overtime to produce masks and sanitiser.

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While Others Shifted To Work From Home, ASHAs And Anganwadi Workers Performed Additional Field Duties During The Lockdown

Basanta Kumar Kar, a Nutrition expert said that Anganwadi workers and ASHAs took the roles of a ‘Nutrition Warrior’, ‘Corona Warrior’ and ‘Lockdown Hero’ during this deadly pandemic. He added,

By promoting social distancing norms, they helped in implementing COVID appropriate behaviour and prevented infection, malnutrition and hunger. They could avert the crisis and an impending nutrition famine by providing ration door-to-door. In numerous cases, they referred severely affected malnourished children to the Nutrition Rehabilitation Centres (NRCs) contributing to child survival.

They were also given the task of tracking the migrant workers, do contact tracing for people getting the infection, providing ration and nutrition door-to-door and raising awareness about preventive measures.

Debabrat Patra, Associate Director, ActionAid, Odisha asserted that the one good thing that the pandemic has done for the frontline workers is that the country, today, recognizes the importance of Anganwadi workers and ASHAs like never before. He said,

We are now much more aware about those who are responsible for the last mile delivery of essential medical and nutrition services. Only an ASHA will have the complete health profile of the ward designated to her. Over the course of their work, ASHA and Anganwadi workers build an interpersonal relationship with community members. This helped in keeping close track of those who can potentially get infected with the coronavirus.

Primary healthcare workers are also ‘Nutrition Warriors’ who are fighting malnutrition on the frontline: Expert

Pravin, 40-year-old Anganwadi worker in Kota, Rajasthan, is a widow who struggled to make ends meet during the lockdown as her daughter, a 22-year-old lost her job as a helper at a school and Pravin, herself was burdened with a lot of extra duties.

I was very scared at first because the disease was spreading like a wildfire. My daughter provided me moral support during that hard time. She used to rush to get warm water, sanitiser and fresh clothes for me as soon as I used to enter the hours after performing field duties. She was scared too but she never brought it up with me, said Pravin, who had to shut down her Anganwadi centre for two months during the lockdown.

While they continued working on the frontline, many women community workers faced lack of safety gears to protect themselves from coronavirus. Nirmala, a 42-year-old ASHA worker in Chaksu Block of Jaipur, Rajasthan said,

We did not receive any face mask or gloves or face shields from the government. We were asked to buy masks ourselves or use cloth to cover our face. We were asked to go out, survey households and perform other duties without armouring us with safety measures. Why did the government ignore its foot soldiers like this? What is the use of appreciating us in public but still avoiding our demand of providing us with safety gears?

Neeta Bhatnagar, 50-year-old resident of Moradabad city, Uttar Pradesh who has been working as Anganwadi Worker since 1998 also highlighted that during the initial days of COVID-19 induced lockdown, they were directed by the officials to go door-to-door and sanitise the hands of all household members, in a bid to inculcate hand hygiene habit but they were not provided with sufficient hand sanitisers. She said,

ANM (Auxiliary Nurse Midwife) gave us some sanitizer and when I complained that the quantity was too less, I was told to mix water and continue with the work. So, I had to buy sanitisers out of my own expenses. My expenditure and workload, both, increased during that period. I am not from a well-to-do family and so I had to cut short some of my personal expenditures to buy masks and sanitisers.

Ms. Bhatnagar receives Rs. 5,500 as honorarium per month.

Anganwadi workers educate families in rural areas about nutrition, health and hygiene

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Poor Income, No Social Security, Dismal Work Conditions Are The Biggest Issues Facing Grassroot Health Workers

According to some Anganwadi workers and ASHAs, they are overburdened with work which also include census work, getting voter ID cards, ration cards and Aadhar cards made for the people in their designated areas and perform routine stock-taking, maintaining of accounts and so on. They are also called upon to do other administrative work by block officers and district collectors when needed. They do not get a fixed monthly income or benefits and receive honorariums in lieu of their work which they do without any provision of weekly leaves. Most of them have not received any extra wages for the COVID-related responsibilities undertaken by them. On the issue of low remuneration and no social security, Ms. Nirmala highlighted,

I have given more than 15 years of my life to being an ASHA worker. But I get only Rs. 2,700 per month and some incentives based on other works like Rs. 300 for taking a pregnant woman to a government hospital for delivery, Rs. 75 per day for conducted polio immunization drive. We have been demanding the legal minimum wage from the government, but the government has been deaf to our demands. I have only 572 people in my area and not more than 7-8 deliveries take place in a year. But we provide care to the pregnant women for whole pregnancy period until she recovers properly after the delivery.

Acknowledging the problems faced by Anganwadi workers, Dr KK Pathak, Anaganwadi Nodal Officer, Rajasthan said,

They are low paid employees. In Rajasthan, they are getting Rs. 7,500 per month as honorarium. I don’t think it is enough for them to live a dignified life. We have almost 62,000 Anganwadi centres in the state and most of them work in harsh conditions and face range of issues like poor condition of the building, lack of space. Sometimes, the lack of cooperation from citizens also creates challenges for them especially when they refuse to send their children to the centre. But these women defy all odds and perform their duties well. The state is thankful to them. We have been trying to improve their condition but there is still a long way to go. Right now, we are not getting adequate funds from the centre. But when we get sufficient funds, it will be utilised in making things better for them.

However, unlike other states, the state government of Kerala is providing some social security to these women. According to Karthyayani VC, Chairperson, Anganwadi Workers Welfare Association, Kerala, the state government provides them with benefits such as pension and free medical care.

Apart from low remuneration and no social security, lack of adequate infrastructure is another major problem that Anganwadi workers face. The remote village of Pujhariguda in Nabarangpur district of Odisha is home to 42-years-old Hemalata Nayak who runs a small Anganwadi Centre. She receives a monthly honorarium of Rs. 7,500.

I have been working here for the last 10 years. I spend my day managing the daily meals, preschool lessons, health and hygiene and counselling pregnant and lactating mothers. The major issue I face is the lack of adequate space in the centre. It is very small, Ms. Nayak said.

Primary healthcare workers ensure that children in rural areas are vaccinated as per the schedule

Not only Ms. Nayak, Sunita Bhatt, Anganwadi worker for the last 20 years in Ukhimat town of Rudraprayag, Uttarakhand, also faces problems in running the Anganwadi centre due to insufficient space. She said,

My Anganwadi centre does not have a separate kitchen and store for keeping medicines, grains and other such things. Everything is in one room where children also sit and we teach them. It gets too congested.

Ms. Bhatt further said that being a mountain state, the frontline workers in Uttarakhand face challenges due to its geographical conditions, especially due to lack of adequate transporation. She said,

I am used to walking 3-4 km daily because there is no road connectivity from my village which is in the interiors to the main road. I get Rs. 7,500 per month but a lot of my income goes to cover transportation cost. Travelling is very expensive here. It takes almost Rs. 500-600 to reach our head office in Rudraprayag block. On top of that, the government does not send food grains to my centre. It just transfers money to our account and we have to buy the required items. Because of the lack of road connectivity and better transportation, we face a lot of difficulty in accessing the markets and getting the grains picked from the market and dropped at the centre.

Since they are in direct contact with people, the Anganwadi workers are often at the receiving end of complaints from the community especially when there is a shortage of food supplied or the quality of food is not good. Neeta Bhatnagar said,

Motivating people to adopt better nutritional and health practices is not easy. It becomes even more difficult when the community members doubt our integrity. Many times, we do not receive sufficient food grains from the government. In my centre, there are 62 children who are 7 months to 3 years old, 12 children who are 0-6 months, 12 lactating mothers and 9 pregnant women. But the ghee (clarified butter) packets that we have received from the state government are only 60. And on top of that, the quality of that ghee is very poor. People come to us, question us and misbehave with us because of the things that are not even under our control. Most of the households who have registered their children with Anganwadis are motivated by the services and food items provided here. We are getting insufficient ration from the state, but the people think that we not distributing and are either selling it off in the market or consuming it ourselves. Our centre should ideally get 120 kgs of wheat but we get about 80 kgs. We cannot but the extra grain from our pockets as even we are living hand-to-mouth.

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Hope For A Better And Healthier Country And Interpersonal Bonding With Community Keeps These Health Workers Going

The Anganwadi workers and ASHAs said that working in the primary healthcare sector has given them a sense of empowerment and fearlessness. Sunita Bhatt said,

Prior to being an Anganwadi worker, I used to hesitate in going anywhere alone. But now I can move about freely. My confidence has increased.

Not only this, the bonding developed between the community and AWWs and ASHAs also helps them to continue working even after facing harsh conditions. Ms. Archana Sharma, ASHA worker in Kotdwar district of Uttarakhand said,

I accompany patients to facilities and visit their homes to take care of them. I spend so much time among the community that I feel like they are all my family members. Sometimes, when a woman gets pregnant, I am the first to know before she even tells her family.

According to Priyanka Bajaj, Nutrition Expert and Riya Gupta, Research Officer at IPE Global Limited, a Delhi based consultation firm, it is high time that the government should work on building the motivation level among the grassroots workers. They said that more focus needs to be given to enhancing their service delivery skills and developing a problem resolution approach as they are extremely important in the last mile service delivery.

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NDTV – Dettol Banega Swasth India campaign is an extension of the five-year-old Banega Swachh India initiative helmed by Campaign Ambassador Amitabh Bachchan. It aims to spread awareness about critical health issues facing the country. In wake of the current COVID-19 pandemic, the need for WASH (Water, Sanitation and Hygiene) is reaffirmed as handwashing is one of the ways to prevent Coronavirus infection and other diseases. The campaign highlights the importance of nutrition and healthcare for women and children to prevent maternal and child mortality, fight malnutrition, stunting, wasting, anaemia and disease prevention through vaccines. Importance of programmes like Public Distribution System (PDS), Mid-day Meal Scheme, POSHAN Abhiyan and the role of Aganwadis and ASHA workers are also covered. Only a Swachh or clean India where toilets are used and open defecation free (ODF) status achieved as part of the Swachh Bharat Abhiyan launched by Prime Minister Narendra Modi in 2014, can eradicate diseases like diahorrea and become a Swasth or healthy India. The campaign will continue to cover issues like air pollution, waste management, plastic ban, manual scavenging and sanitation workers and menstrual hygiene.