She tries to fix her white sari with a blue border as she sees the boat clinic approaching. Shahida Khatun, 35, tries to give some last-minute tips to the women standing around her. She chides a mother for not coming for the last session on immunisation. She looks around to see if there all the mothers with new-born children have arrived with their babies.
The white sari with a blue border is not an ordinary attire in an inaccessible riverine island in Assam. An island that is accessible only by a boat. This is the most important uniform that possibly can change many lives in an island. ASHAs are community health workers instituted by Government of India’s Ministry of Health and Family Welfare as part of the National Health Mission (NHM).
Early in the morning, Shahida had informed 30-year-old Moifun Nessa that the boat clinic (nauka clinic) will be coming. Moifun brought her daughter to get her dose of routine immunisation. She rues, “We live in isolation here. There is no electricity, the only school is dysfunctional. The boat clinic is our lifeline. We are fortunate that a doctor and the entire medical team reaches us. I would have missed it had ASHA didi (sister) not informed me early in the morning.”
Moifun had undergone tubectomy at the behest of the ASHA didi, Shahida Khatun of Ekroti char, a riverine island. Moifun tries to persuade her own sister to go for tubectomy, “Look at me, I am stress-free. I don’t have to worry about unwanted pregnancies anymore.”
ASHA worker Shahida Khatun flashes the black cellphone which has been given by the government after her training period. “Everyone in this island has my phone number. I was given a bicycle too but it needs repair, so I left it at home.” She receives a phone call in the middle of the melee around her. She is rather stern on the phone, “I had told you to go for a tubectomy. Your neighbour Moifun listened to me. And see, she is carefree now. You already have four kids. How will you feed or educate another one?” She grumbles as she hangs up her phone.
The team from the boat clinic led by Mousumi Duwarah trudges arrives at the village square. Mousumi is the District Programme Officer of the boat clinic project in Assam’s Sonipur district. The women break into a smile as they see Mousumi baideo (sister). The first person Mousumi speaks to is Shahida, the ASHA worker. Shahida is her livewire to the island. She is like a sentinel in this precarious riverine island also known as a char. It is Shahida who has been entrusted the responsibility to network with the women in the island — keep track of the expecting mothers and their health check-ups, the new-born babies and their immunisation records and convince them about family planning methods.
In June 2004-2005, the Centre for North East Studies and Policy Research (C-NES) launched this unique initiative – to provide mobile health services to the poor and the marginalized on the islands in Dibrugarh district. These specially developed boats equipped with OPD, laboratories on board as well as pharmacies, first to one, then three and now reach thirteen districts in Assam through a Public Private Partnership (PPP) with the National Health Mission (NHM), Government of Assam.
“The goal is to take sustained health care to lakhs of persons on the islands, for the first time since independence, with a special focus on women and children, who are the most vulnerable in difficult conditions. Assam has India’s worst Maternal Mortality Rate at 328 MMR (Registrar General of India, Special Bulletin on Maternal Mortality in India 2010-12) higher than Bihar or Uttar Pradesh and a high Infant Mortality Rate at 54 IMR,” says Bhaswati Khound Goswami of C-NECS.
Providing ANC, PNC check-ups along with advocating institutional deliveries has been priority with all the Boat Clinic health teams especially crucial for a state like Assam. The organization started with one boat and seven staff in Dibrugarh district in 2005, with support from district health and administration. The success in the intervention drew the attention of UNICEF and the NHM, Government of Assam, resulting in the spread of the Boat Clinic programme to 13 districts – Dibrugarh, Tinsukia, Dhemaji, Jorhat, Lakhimpur, Sonitpur, Morigaon, Kamrup, Nalbari, Dhubri (2 units), Barpeta (2 Units), Bongaigaon and Goalpara.
Each district has 15 staff headed by the District Programme Officer (DPO) who is the key person in organizing district plans and coordinating among the team, district health departments, district administration, NRHM and the community. His or her team includes two Medical Officers and paramedical staff including two ANMs, a GNM, a pharmacist and one laboratory technician besides three community workers and a four-member boat crew. The work of the boat clinics has led to remarkable results: On an average, 18,000-20,000 people are treated every month in the districts, individuals who were earlier beyond the reach of government programmes because no doctors or paramedics would go on a regular basis. The only time, villagers say, they would see a doctor on site was during an emergency like a major flood. Otherwise, they had to travel long distances at great cost and risk to get treated. Today, the services come virtually to their doorstep. Till April 2016, over 1.88 million people have been given basic health services.
Sanjoy Hazarika, Managing Trustee of C-NECS appreciates the role of the ASHA workers, “I believed in this idea even when others did not. I believed in the capacity of ordinary people in Assam to defy the odds and bring about change. The boat clinic is platform and an application for every possible service and idea, be it solar, education, health or even banking. You can take these applications to the field. The credit for the success of the project should rightly go to the courageous teams including the boat crews who deliver the service which is on the basis of rights and entitlements, not acts of charity. The key to many of these activities lie with the village health workers, especially the ASHAs who are there 24×7 and know everyone as these are their homes. Without their presence and work our outreach would not be as impactful.”
The work of the Boat Clinics has led to remarkable results: On an average 18,000 – 20,000 people are treated every month in the districts, individuals who were earlier beyond the reach of government programmes because no doctors or paramedics would go on a regular basis. Till July 2016, over 1.8 million (18 lakh) people have been reached with basic health services.Apart from the routine health services, the ASHA workers are also responsible for disseminating information on family planning methods which includes counseling for spacing and permanent methods, distribution of Condoms, Oral Contraceptives, Emergency Contraceptives, IUD Insertion, Tubectomy and Vasectomy. “It is difficult to convince these people to go for permanent methods of family control. But they have started adopting temporary methods, mostly contraceptive pills and condoms,” says Duwarah.
ASHA worker Sahara Khatun who is responsible for Dubai and Pub Lanke char knows the importance of her uniform. “Not everyone gets to wear this sari. It’s an asset for me. I have undergone several rounds of training. And I enjoy the trainings that have taught me many new things about mother and child care. I get to meet other health professionals including doctors. I am leading a meaningful life which would not have been possible had I not been an ASHA,” she says.
Sahara knows the importance of a boat clinic in an inaccessible place like a riverine island. “Something like this was unimaginable few years back. When I was expecting my baby, I could not even imagine that services would virtually come to our doorstep.”
Sahara has been trying her best to convince the women on the benefits of having a small family. “I tell them that if you have limited children, you can feed them well. If you cook a special dish or meat or fish curry, all of you can have your fill. Otherwise, it will be a constant struggle for food every day,” she says on a very practical note.
C-NES and the New Delhi based Population Foundation of India(PFI) have been working together since 2009 focusing on propagating Family Planning methods, Reproductive Child Health (RCH) and awareness building on Family Planning amongst the island dwellers. “The people living in these chars and chapories normally do not wish to give up their traditional mores. The unwritten code is that the senior head of the village takes all decisions concerning to the people in these areas. They ask villagers not to discuss family planning methods. Gradually, through the capacity building training of frontline health workers, sensitization meetings with village heads, PRI members, group discussions, counselling and special awareness programs mainly among eligible couple, giving emphasis on women’s health, the perceptions of these very same people began to change. Even those who had initially opposed us, are now co-operating with us,” adds Bhaswati Goswami of C-NECS.
Life is tough in all chars. And it becomes a gruelling task when it comes to women’s health in particular. Tapajuli-Mazitbhita (henceforth Tapajuli) is a char village on the bank of the river Beki in the Barpeta district of Assam. It has a total of 263 households. This village is highly susceptible to the annual floods. Apart from being submerged under flood waters, the village is vulnerable to severe erosion. While studying the activities of the ASHA workers in Tapajuli and the 2250 other char villages of Assam, the flood and erosion factors must also be seen as contributing to the difficulties of the workers. Tapajuli has no paved roads, electricity or running water. The nearest market is Janata Bazar, about 5 km away and the nearest civil hospital is at Kalgachia, about 14 km away.
Shalim M Hussain, a researcher says, “It is important to note that because of erosion, the people living in Tapajuli char have to constantly relocate: sometimes from one side of the river to the other and often to an emerging sandbank from one that faced the danger of erosion. Since the dais (traditional midwives) come from the same community, they have to face the same problem. Erosion in the Beki River is severe and more often than not, the people have to relocate every couple of years. However, with the coming of ASHA workers, they are in better hands.”
Maryam, the ASHA who works at Tapajuli char and has been associated with JHAI Foundation, an ngo says, “Institutional deliveries were not preferred by the residents of the char in the past was simply one of lack of access. In association with the volunteers and employees of Jhai Foundation, Maryam has conducted a series of awareness campaigns about childbirth, reproductive health, care of new-born babies and reproductive health.” Jhai Foundation itself has tried a top-down approach for disseminating information. They first convinced the panchayat president and members, anganwadi workers and community leaders and then took them from house to house talking about the need for institutional delivery and other accompanying concerns.
An ASHA worker at Kalgachia civil hospital in Barpeta district claims that she could convince 42 men to go for vasectomy in 2016 and had received no complaints from any of them. As far as female sterilization was concerned, she said that she advised women to opt for birth control pills or the Copper T.
ASHA workers have been able to bring about an attitudinal change. Many families were reluctant to pay the token amount of one rupee for a packet of contraceptives which were earlier issued for free. ASHA worker Maryam said, “The token amount for the condoms ensured accountability. Earlier when they were issued for free, people would take a large number of condoms and then just discard them without use. Now that they had to pay an amount (though it was very little), the cavalier attitude towards contraceptives was gone.”
The four ASHA workers at Kalgachia said that they were initially the butt of jokes. People were curious to know how much they got paid for doing the ‘khalas’ of a delivery and also if it was appropriate for them to leave home every day, go frequently for training programmes etc. Now, they had ‘izzat’ (respect). People had begun to understand their importance and were willing to come forward and discuss issues like contraceptives and condoms which were earlier considered taboo.