Monday, December 22, 2008

Social Health Activists they are – Will the government accredit them?

SunderBai is a Kokana adivasi lady, and a Pada Swayam Sevak in her hamlet, about 6 kms from the Saiwan Primary Health Center (Dahanu Taluka, Thane District, Maharashtra). She was trained by Support for Advocacy and Training to Health Initiatives (SATHI) to diagnose minor ailments, conduct health awareness, and to undertake activities that are neglected by the government health system, such as chlorinating drinking water. She takes pride in the work she does – she took the initiative to undergo further training, and now makes and dispenses herbal ayurvedic medicines in addition to the allopathic medicines that she learned to dispense as a result of her training by SATHI. She was amongst 48 women recognized in 2003 as Community Health Workers by SNDT University in Mumbai.

KuppiAmma, a health auxiliary in AK Thanda village (Harur Taluka, Dharmapuri District, Tamil Nadu), was trained by Tribal Health Initiative (THI). In addition to diagnosing and treating minor ailments, she makes sure women with infants get post-natal examinations at health camps conducted by THI in her village. She was chosen as a health auxiliary on account of her being trusted in her village; having finished her own child-rearing activities, she is looked up to in issues regarding child rearing. KuppiAmma is also a community organizer, and is now leading her village in its shift to organic farming techniques. Under her leadership, members of her Lambadi tribal community are attempting to re-learn their traditional embroidery that is the verge of extinction. She is a community organizer, health educator, and trusted partner in the village’s social affairs.

If I had to formulate a common designation for these remarkable women, it would be “social health activist.” And they are that because of their stature in their village, their leadership qualities, and the quality of the training they received. Yet, these are not variables considered by the government when filling the post of ASHA – an ‘accredited social health activist’ – under the National Rural Health Mission. The government requires that the ASHA have studied at least till the 8th standard in school. While this requirement has been relaxed if no one in a village qualifies, it imposes a restriction in villages where there may be women who are school-educated – they must be chosen under the government’s requirements, even if it means overlooking a more trusted woman in the village, who might better embody the leadership qualities so necessary in a social health activist. “I applied for the post of ASHA, but was told I was ineligible – unfortunately, I never went to school even though I was trained by good doctors to diagnose diseases,” says SunderBai.

NGOs like SATHI and THI require that a woman chosen to be a Community Health Worker (CHW) fulfill one requirement above all else: that she be trusted by her village. Education level is only secondary, if a requirement at all. In fact, SunderBai and KuppiAmma prove that completely illiterate women can, given the right training (SATHI uses pictorial manuals to train illiterate people), be extremely competent primary health care providers. NGOs who train CHWs also realize the need for compensating them – these ladies maintain an agricultural day-job and need to be compensated for the time they spend mobilizing the community on issues of health. I met community health workers in four parts of India this past summer – none were paid very much (their pay ranged from Rs. 350 to Rs. 700 a month), but this money is important to these women, in addition to the satisfaction and pride that their work gives them. The government’s approach of not paying ASHAs and relying on them to volunteer their time, energy and knowledge, has no basis, either in theory or in the experience of NGOs who have trained CHWs in the past.

By appointing women who may have already been trained in a hamlet (like SunderBai) as an ASHA, the government would not only save time and money needed to train another lady, but would also gain a well-trained and trusted health worker. Furthermore, by using training methods like those that have been used by SATHI to successfully train illiterate women, any requirement for school-education can be removed, thus ensuring that the woman with qualities most suited to the job, is chosen. Finally, the government must remunerate ASHAs for their efforts. Otherwise, the ASHA program runs a risk of failure, much like a CHW program instituted by the government in 1978. Then, 92% of CHWs were male, underpaid at Rs. 50 a month, and under-trained – they received only two weeks of training at the nearest Primary Health Center. The government has done well this time around, to insist on hiring women as ASHAs, and to have continuous training and discussion as part of the training-strategy. However, it would do much better if it compensated ASHAs adequately, and required only that she be chosen by her village Gram Sabha, rather than also impose ad hoc education requirements that put her at risk of becoming simply the lowest rung in the government health machinery.

A shorter version of this article was carried in the Oct 2008 edition of Dishaa

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