A story of hope: ASHA in the hamlets

DH trails three accredited activists as they take healthcare to remote communities.

I am standing across Susheela Sannappa’s home. Her mud hut is flanked by tall trees overgrown with pepper vines. Susheela waves at me to come over and then rushes inside to attend to the rice, dal and sambhar she is making over firewood. I climb a dusty, uneven path, and survive a slip or two before reaching her hut, which, she tells me, was partially damaged by an elephant recently.

“We can’t afford cooking gas. I cook on an earthen stove and that takes time. I wake up early to be on time for my work,” Susheela says as she emerges in a plain pink sari, her uniform as an ASHA worker. I give her a string of jasmine flowers, which she wears on her hair right away. I am wearing a pink sari too, especially for this visit, but Susheela is in too much of a hurry to notice.

Just as we set out, the 32-year-old sees people huddling around a water tank with plastic pots. “We get water once in three days,” she says, calling out simultaneously to her husband to fetch water. She is shy of addressing her husband Sannappa by his name, so she calls him Mani, short for their son’s name Manikanta.

It is 8.50 am. I have travelled from Mysuru to accompany Susheela on her daily visits to the D B Kuppe forest range of the Nagarahole Tiger Reserve in H D Kote taluk. I have been a health reporter for 19 years but this is my first time shadowing an ASHA worker.

ASHA expands to Accredited Social Health Activist. The Ministry of Health and Family Welfare employs women as ASHA workers for last-mile delivery of healthcare and other government schemes to underserved populations. They are chosen from within the community, one per 1,000 population in the rural areas, and 1 per 2,500 in urban areas.

Susheela is a healthcare facilitator for 258 families living in her tribal hamlet of Golur Haadi, and the adjacent Balle Haadi. An ambulance takes 1.5 hours to get here from the nearest government hospital. The closest primary health centre (PHC) is 8 km away – with no ambulance, facility for delivering babies, or staff except for a contract doctor.

Fear of syringes

We are headed to Balle Haadi. KSRTC buses plying the route are too few and private vehicles aren’t allowed to halt because of forest department rules. After waiting for 20 minutes, Susheela signals a press van to stop. Driver Muju is returning after delivering newspapers to Bavali checkpost at the Karnataka-Kerala border. He charges me Rs 20 and Susheela half the price as she is an old customer. “Wish the government could give us a moped bike,” says Susheela.

We alight the vehicle and begin walking amid tall, leafless trees. Susheela’s job is to facilitate 40 baseline health services. Today, she has to conduct a mosquito larval survey in stagnant water in pots and tanks, provide counselling on family planning, monitor pregnant women and new mothers, track the immunisation of young children, and record feedback about guarantee schemes.

ASHA worker Susheela Sannappa (middle) checks on the health of an infant in a tribal hamlet in D B Kuppe range.

Houses are spread out. Not a single house has water and electricity connections, or even a toilet. The heat is getting worse. The mud under my feet cracks as I walk. “During the rains, the paths become slippery and full of puddles, making it more difficult to walk. Sometimes, ambulances arrive after a baby is delivered, or the delivery happens en route,” Susheela says.

It’s ironic that emergency healthcare is hard to access here. It is just 98 km from Mysuru, a healthcare hub thanks to the visionary Maharajas. It boasts the century-old K R Hospital and also tele-ICU facility at taluk hospitals.

The usually quiet Susheela breaks my chain of thought. She has something “funny” to share. In the past, elders like Kencha, Gowri, and Devi have refused to get into an ambulance after it made it to their doorstep – free of cost. “Both elders and ambulance drivers get mad at me (in such cases),” she explains. They fear modern healthcare – some dread needles and syringes, others prefer local herbs. For younger folks, the fear is monetary. Going to a taluk or town comes in the way of earning their daily wages.

‘Sudha!’ Susheela shouts outside the first hut in sight. A 25-year-old woman, six months pregnant, comes out. She enquires if I am a nurse or health official!

“Why are you not coming to Anganwadi for lunch? The government provides free food for pregnant women,” Susheela asks Sudha. “Suseele, I can’t walk that far in the sun,” says Sudha, who’s fifth time pregnant. She prefers the earlier provision of delivering the ration home.

Susheela says despite counselling on contraception and provision of free oral pills and condoms, the residents don’t “stop”. They consider kids as assets. Her next visit is also upsetting. “Why are you still chewing tobacco?” Susheela complains on seeing Lalitha Ganesh’s red-stained mouth. Then she strokes the face of her one-month infant, and asks about her health.

We pass many locked huts, a sign that residents have gone to work or migrated to Kodagu or Kerala as they are yet to get land rights. “Migration discontinues the natal care, and immunisation routine,” she rues.

Sometimes, residents have more questions for Susheela than she has for them. An 80-year-old Lingamma, sitting on the ground, asks: “O Suseele! How can they give the same amount of ration in the tribal nutrition kit to all families because the number of family members vary per household?”

Susheela has no mobile network, so she is taking down details on paper instead of uploading them on the ASHA Soft app. The nurse at the PHC is then supposed to feed this data into the system but that post has been vacant for a year.

We head to Balle elephant camp. We meet Dasara elephant Bheema who had been brought for an operation to chase rogue elephants. Susheela checks on mahout Vinu. He “misses” his Dasara elephant Arjuna who died during a rescue operation last December. A little ahead, we cross paths with firefighters preparing for the summer. At Golur Haadi, we visit a community hall where 16 children of a government school, of classes 1 to 7, study in one room. A private company is considering supporting it under CSR funds and guest teacher Hanumanthu consults Susheela about what demands they should draw up.

Susheela gets home by 4 pm but has no time to rest her tired feet. She heads straight to a well a kilometre away. She needs to wash her uniform because she has only two sets. I dash back to Mysuru.

Vicks, allergy and blame

The next day, I arrive at Nehru Nagar, an urban slum, 8 km from the centre of Mysuru. I am clad in a pink sari again and this time my efforts get noticed as ASHA worker M Deepanjali remarks, “Madam, you are wearing a saree like us.” Albeit Deepanjali and her coworker Sunitha Santhosh are wearing pink salwar-suits today.

I park my two-wheeler near Deepanjali’s home. They pack registers, weighing scales, ORS packets, blood pressure monitors, condoms, oral contraceptive pills, and iron and calcium supplements in their bags. We set out at 9.10 am. People welcome us inside their home and offer water, coffee, juice or bananas.

Like the tribal hamlets I visited, here too, while pregnant women welcome antenatal and postnatal care benefits by the government, they refuse to visit Anganwadi for lunch. Working women say they would like to receive their rations at home.

The preference for a son is still strong here. The talk on contraception is hush-hush. Women hide their third or fourth pregnancies and risk complications. They hide the ‘news’ out of embarrassment as ASHA workers advise them to keep a gap of three years between pregnancies. In one such case, the haemoglobin level of a seven-month pregnant woman had dropped low. “We were able to arrange a blood transfusion in time. She gave birth to a healthy boy," remembers Sunitha.

Now Deepanjali is checking the blood pressure of three-month pregnant Arfa Mohamadi. Arfa shares the news that her father spent Rs 75,000 in a private hospital for the treatment of his leg infection.

The residents trust Jayadeva Institute of Cardiology, but fear the quality of treatment at other government hospitals in Mysuru, the home district of Chief Minister Siddaramaiah. “This despite creating awareness,” laments Sunitha.

And if a government treatment goes wrong, they blame ASHA workers. Deepanjali recalls a case: “A woman rubbed Vicks on her child after he had received a DPT vaccine early in the day. This led to an allergy. Both parents came to my home, scolding me. I went to their place and stayed  until 10 pm, changing cold cloth packs till the pain and allergy subsided.”

Like doctors, ASHA workers say they are a call away during emergencies. Despite their commitment, Deepanjali is saddened to share that they were verbally attacked during Covid by people claiming ASHA workers spread the infection.

An hour later, I hear Kannada song ‘Deva ninna beduve’ coming from an Anganwadi. Deepanjali enters the Anganwadi to monitor underweight children. A smile spreads on her face. The weight of a four-year-old boy has gone upby a kilo, thanks to the consumption of ‘Pushti’ nutrition powder, milk, rice and dal provided at the centre. Her smile is soon replaced by a sigh. A mother, who has come to drop off her child, tells her, “Deepa, ask the government to provide vegetables. The khichdi mix just has rice, mustard seeds and lots of chilli powder. Anganwadi workers spend their money to buy vegetables for the khichdi.” Deepanjali assures her she will report the feedback to the designated PHC.

We keep walking, minding the dug-up lanes. Residents peer out of their homes to ask Deepanjali and Sunitha about the status of their ration and ABHA cards. ABHA or Ayushman Bharat Health Account is a digital health ID that facilitates easy access to medical records.

It’s 4 pm. We are starving. We say ‘bye’ to each other and head home. For the residents of Nehru Nagar, I was the ‘Press madam’ and I am going back with a lot of “problems” they want me to report on.

Underpaid but unstoppable

ASHA workers form the last leg of India’s healthcare programmes and there are over a million of them. D Nagalakshmi of Karnataka Rajya Samyuktha ASHA Karyakarthara Sangha says they have won the respect of the community. 

Nagalakshmi tells me about an ASHA worker who pledged her earrings to buy blood for a pregnant woman from a poor family. For another pregnancy case, Susheela paid for a jeep to get help faster. “Kavitha Karthik delivered a boy,” she recalls. Farhana, an ASHA worker in Bengaluru, saved a 23-year-old from ending his life. It was a case of inter-faith love and families on both sides were opposed to it. Some have prevented child marriages.

One area where they haven’t been able to foster much change is getting women to report cases of domestic abuse. Farhana says, “They refuse to file a police complaint for fear of the stigma, for the sake of their children... also they don’t have the time and means for legal battles.” Some ASHA workers avoid involving the police, fearing it can break families.

It is usually the neighbours who tip off ASHA workers. Often families don’t mind their intervention because they are known to each other. “They consider us family. We counsel the couples to co-operate and live with understanding. Sometimes, we threaten them with police action,” says Susheela.

Not being able to prevent marriages in close blood relations to avoid the risk of genetic disorders is another regret. It’s also difficult to
persuade men to get sterilised. 

Most women take up ASHA work to boost household income. Susheela joined after marriage, on the suggestion of her brother Ravi and husband. Deepanjali enrolled after her husband was bedridden because of a liver ailment. He died of it a little later. Sunitha’s husband is an autorickshaw driver.

The monthly honorarium for an ASHA worker is Rs 5,000 and some make up to Rs 7,000 with incentives. ASHA workers say they are not only underpaid but also that the payment comes late and they borrow money to tide over tough times. Hiking their fixed pay to Rs 15,000 is a long-pending demand. They also want the government to provide them a smartphone with Internet connectivity, and transport to access remote locations.

But Deepanjali points me to the upside: “I am proud that I could educate my two children as a single mother. Despite challenges, I get joy and contentment from my work.”

When ASHA workers intervene in complicated pregnancy cases, Nagalakshmi says families offer sweets and lunch, and bless them with all their heart. For young girls like Bhagya from Balle Haadi, Susheela, their akka (sister), is a role model. Mothers in the hamlet want their daughters to study well and become ASHA workers. SSLC is the minimum educational requirement for the job.

Over a call, Kaushalya, an ASHA worker in Koppal district, tells me the biggest compliment she has received: “Lakshmi lost her child during a home delivery. I took her to hospital the second time. It was a complicated pregnancy. She gave birth to a girl child and named her after me. She also hoped the child would grow up to become like me. We often make critical decisions on behalf of the families. When it saves lives, it is gratifying.”

What ASHAs want

1. Increase fixed monthly honorarium from Rs 5,000 to Rs 15,000.

2. Transport to access remote locations.

3. A smartphone with Internet connectivity to enter data.

4. Fill 1,369 vacant positions across Karnataka.