Fighting TB: ASHAs seek stability, better pay and health insurance

In 2021, 4.94 lakh people died from TB in India. During this period, 316 out of every one lakh people were TB patients. Among those over 55 years old, the rate was even higher, with 588 out of every one lakh being affected. This indicates that the average TB incidence among the elderly is significantly higher than the national average. In tribal areas like Jhabua, this situation is worsened by the fact that many elderly patients are unable to travel to government hospitals for their medication due to physical weakness. Kanku Gamd, an Accredited Social Health Activist (ASHA), works to bridge this gap. 

A resident of Chhapri village in Jhabua district, Gamd has been working as an ASHA since 2006. With the Kharif season approaching, she is preparing to sow cotton and maize in her 2 bigha fields. However, as soon as she hears of any TB patient in her village falling ill, she leaves everything to attend to them.

Her journey as an ASHA was initially bumpy. For the first five years, she did not receive any honorarium for her work, but she persisted. Now, after almost 18 years, she has become the key person in the village for health-related matters

According to the Madhya Pradesh government, there are a total of 256 ASHA workers in the Rama block of Jhabua. Whereas their total number in the district is 1626. Their main job is to ensure the access of villagers to the health facilities available in Anganwadi, Sub Center and Primary Health Center. In this, child delivery and ensuring maternal safety are the main ones. Along with this, they also work to spread awareness about the right treatment of TB, explains Gamd.

“When we find symptoms of TB in a person, we give them a box in the evening. In the morning, he gives a sample of his phlegm in it, which we give to the community health center,” Kanku Gamd adds.

From the villages, the phlegm sample goes to the nearest government hospital. After testing, the report is given to the ASHA worker through the community health officer. That is, ASHA workers play a key role in all the stages from TB sample to treatment. However, it is not easy for them to work among TB patients in tribal areas like Jhabua.

'ASHA', to overcome disease and superstition

Kanku shares a story about a patient from her village who, after taking medicine for two months, experienced an increase in body heat and then turned to a Badwa—a Tantrik (witch doctor) popular among tribal communities.

“It is a big challenge to wean patients off the Badwa and get them to continue their medication. When patients start taking medicine, the Badwa often says, 'I will give you jungle medicine; you should not take this medicine,'” Kanku explains.

Convincing patients to stick with their prescribed medication is a constant struggle. Kanku says she has to continuously educate the patients and ensure they do not discontinue their treatment. Despite her efforts, she sometimes faces conflict with the patient's family members.

"tu bulava aaveli taa se lunga 5 laakh rupiya" 

Kanku says this in the Bhili language while describing the conversations she has with TB patients. This means that if a woman's husband dies during TB treatment in a government hospital, the woman will demand Rs 5 lakh as compensation from Kanku, holding her responsible for insisting the patient get treated there.

“Getting a patient to complete the course is a big challenge. Only ASHA workers from the health department work daily to ensure this” she laments. 

Under the Revised National TB Control Program (RNTCP), ASHA workers get honorariums ranging from Rs 100 to Rs 5000 on completion of treatment of TB patients.

Dr. Faisal Patel, head of the TB eradication program of Jhabua, said that ASHA gets Rs 500 if a patient is found positive and another Rs 500 on completion of his course. In this way, Kanku gets an honorarium of Rs 1000 only if a patient is completely treated. But according to Kanku, this honorarium is like a drop in the ocean considering the running around she does during the entire course of treatment of TB patients.

It is worth noting that during the 6 to 7-month course for new TB patients (category 1), ASHA workers have to visit the patient's home 42 times. Only after this, they get 1000 rupees as an honorarium.

Asha' Ensures Nutrition and Awareness

Malnutrition is a problem for 55 percent of TB patients in India. Lack of proper nutrition increases the likelihood of contracting this disease. Vikas Samvad, a social service organization, is working to ensure nutrition in the Shivpuri district of Madhya Pradesh. Arti from Vikas Samvad states,

"We are focusing on eradicating TB through improved nutrition."

As part of this initiative, they encourage TB patients to maintain nutrition gardens and engage in poultry farming. Arti explains that ASHA workers support this effort by assisting TB patients with these activities, thereby helping to fulfill their nutritional needs.

ASHA workers also play a crucial role in organizing awareness camps about TB in the village. Since these workers are in constant contact with the villagers, their efforts result in higher participation in such camps, shares Arti,

Health workers without health insurance

Like Kanku, Kashu Parmar, another ASHA worker in Ruparel village has been doing this work for the last 10 years. Her area of ​​work includes 3 phalias. A phalia is a part of the settlement in this tribal area which has 50 to 60 houses. In this way, it is her responsibility to provide health facilities to more than 150 families of the Gram Panchayat. But she herself does not have any kind of health insurance.

“We take care of everyone from children to the elderly, but no one takes care of us. The government has not even got any insurance done for us till date.”

However, the Asha Benefit Package was approved by the Government of India in September 2018. Under this package, it was said that they would be included in the Pradhan Mantri Suraksha Bima Yojana and Pradhan Mantri Jeevan Jyoti Bima Yojana. According to the government, it was estimated that 9 lakh 57 thousand 303 Asha and Asha facilitators would be benefited under the Pradhan Mantri Suraksha Bima Yojana. Whereas for the Pradhan Mantri Jeevan Jyoti Yojana, this estimate was 10 lakh 63 thousand 670. 

But Kashu has never heard the name of Asha Benefit Package till date. Whereas she believes that due to constant contact with TB patients, there is a possibility of them also getting infected. In such a situation, health insurance becomes even more important for Asha workers.

In a reply given in Parliament in December 2023, the government reiterated this scheme in the benefits given to Asha workers. But till now no data is public about how many Asha workers have benefited from it.

Effect of changing weather

Last April was the hottest April since 1940, with fears that heatwaves could last for 8 to 11 days in May. The continuous warming of the weather has a direct impact on ASHA workers. Comparing herself to an Anganwadi worker, Kanku says,

“An Anganwadi worker has to sit in one place. We have to run around the whole day.”

Like Kanku, Kashu also finds it increasingly difficult to work in these hotter months. Kashu cultivates about 5 bighas of land. When the Kharif crop starts getting harvested in March, it becomes particularly challenging for her to manage her duties as an ASHA worker.

“Now the sun has started shining even in March. During this time, even if you go out for work at 10 o’clock after harvesting, you can work for only 1 to 2 hours.”

Even then Kashu could complete her ASHA duties, like visiting a patient in the evening? But as evening approaches, household chores engages her leaving her no choice but to fulfill her ASHA responsibilities in the day.

 According to Kanku, she works even when she is unwell. Narrating the story of a TB patient, she says,

“A patient refused to take medicine. When I went to his house, he would hide in his field. Last year, in the same month (May), I had a fever, yet I went to his house every day and persuaded him.”

Demand for permanent employment

ASHA workers are the backbone of the health system in rural India. According to an estimate, about one million ASHA workers contributed as 'Covid warriors' during the Corona epidemic. Kanku is constantly trying to make her village TB free. She says,

“We ourselves want our village to become TB free. This affects the patient's family a lot.”

Under the ASHA Benefits, the Central Government has increased the monthly honorarium of ASHA workers from Rs 1000 to Rs 2000. From April 2023 to March 2024, Kanku received a total honorarium of Rs 2,09,730. This includes her monthly honorarium as well as payments for completing various activities. While this amount may seem substantial, in March this year, she received only Rs 8,035. This indicates that Kanku's monthly income is not fixed. Kanku wishes for a permanent government job and also requests health insurance from the government.

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