BY TERESA REHMAN
When she first got her bicycle, Sitarani Das was gawky. She fell down several times as she tried to learn how to ride the bicycle. It took her around 15 days to pick up cycling. She became one of the few women who rode a bicycle in her village. The cycle was given to her by the health department so that she can commute through bumpy roads to the villages assigned to her. However, Sitarani, a ASHA (Accredited Social Health Activist) worker of a village in Assam’s Sonitpur district now confidently sways her way on the bicycle to the 252 households under her jurisdiction and interacts with the villagers, who comprise both Hindu and Muslim population. Come hail or shine, Sitarani is there enquiring about the health of pregnant women, vaccination doses of children, educating people about family planning, menstrual hygiene as well as sanitation and toilets.
She has to track pregnant women from the third month itself and ensure that the pregnant woman completes her dosages of vaccination, iron and calcium tablets. She has to take the woman for a check-up at a government hospital on the seventh month. And ultimately it is her responsibility to take the woman to a government hospital for a safe delivery. From that comes her income, a measely sum of Rs 600 per delivery. She also gets Rs 250 per child when she completes supervising their vaccination from birth till the 10th month.
The most difficult job is to convince couples to go for either tubectomy or vasectomy. “Sometimes, they are so scared that they come back from the hospital gate. I try to explain the economic burden of a huge family. Sometimes, the women might want but the men might not allow,” she says. She gets a small amount for every tubectomy and every vasectomy done.
In order to supplement her monthly income, Sitarani also works as a domestic help at a private residence. But she has to take leave atleast 4-5 days in a month as she has to be present at the monthly vaccination and health camps. This is of course without any kind of remuneration. And she has to rush on her bicycle to enquire if the dosages of vaccines don’t arrive on time.
“Initially I was awkward as some villagers did not heed me. But now, this white sari with a blue border and the bicycle has become a part of my life. I am respected now by the villagers. So much so, that they even bring sweets for me on festive occasions now. Now Eid is coming and I can expect packets of sweets from my well-wishers,” she smiles.
Married with a daughter, Sitarani became an ASHA in 2006 when she was nominated by the ANM nurse who used to come to her village to give vaccines to children and expecting mothers. She had her initial training at a Public Health Centre and has honed her skills through hands-on experience.
Public health workers like Sitarani are important components in the Indian healthcare system. One of the key components of the National Health Mission is to provide every village in the country with a trained female community health activist ASHA or Accredited Social Health Activist. “An ASHA is selected from the village itself and accountable to it, the ASHA will be trained to work as an interface between the community and the public health system. They are local women from the village and that helps us to reach out easily to the villagers, especially in matters of reproductive health as they are used to their customs, culture and language. However, I feel that their remuneration should increase as they work very hard. We are also overburdened by administrative work,” says Kalpana Doley, an ANM Nurse at Samdhara Sub-Centre, with over 10,000 population under her jurisdiction.
Doley adds with a smile, “It has become instinctive with me. Whenever I see a child or a pregnant woman, in a bus or on the streets, I ask them if they have had their vaccination done.”
National Health Mission (NHM), Assam has selected and trained 28798 Accredited Social Health Activists (ASHAs) as a bridge of communication between the community and health service delivery. In fact, NHM, Assam in collaboration with All India Radio (AIR), Guwahati initiated a bi-weekly radio programme for ASHAs namely “ASHA Radio Programme” in August’2007. The touchy music and notes of the title song helped in mobilizing the ASHAs and increase the listenership.
However, ASHA workers have a tough task in hand. Assam had for the tenth successive year recorded the highest maternal deaths in the country. With the Maternal Mortality Rates (MMR) of 300, the State has surpassed the national average of 167. According to the Sample Registration System (SRS) (July, 2011-13), the MMR in Assam of 300 per 1 lakh live births is the highest in the country, the corresponding national number being 167. These findings are part of the National Family Health Survey-4 (NFHS-4) (2015-2016).
When Halima Khatun became an ASHA worker in 2007, she was apprehensive. But now she is comfortable and villagers find it comfortable talking to health personnels and hospital authorities when she is around. “I am on call 24×7. The villagers call me by various names attributed to an aunt like Mahi or Pehi.” Halima who caters to mostly Muslim population feels a palpable change in the attitude of the people. Earlier they would not even talk about contraceptives and other birth control methods. “However, now they have realised and themselves come to the health centres to collect the contraceptive pills or condoms. I am like a family member for most of them now and they confide in me,” she says.
As an ASHA worker, she is also acts as a depot older for essential provisions being made available to all habitations like Oral Rehydration Therapy (ORS), Iron Folic Acid Tablet (IFA), chloroquine, Disposable Delivery Kits (DDK), Oral Pills and Condoms. However, she agrees that she has been able to convince more women to go for tubectomy. “I could convince one man to go for vasectomy and sometimes I take him with me for awareness camps. It is mostly religious sanction that prevents them from going for vasectomy. They say that their janaza or funeral rites would remain incomplete if they undergo vasectomy,” she says.
Vasectomy still has a long way to go in Assam across caste, creed and religion. Many also feel that it will make them impotent. According to the records of the state health department, in the year 2015-16, the total number of male sterilisation in Assam was 4154 as opposed to 44171 female sterilisations.
In fact, female sterilisation is gaining ground. The subtle behavioural change is visible. Salma Khatun, a mother of three married daughters works as a domestic help. She convinced one of her daughters to go for tubectomy. “When I was young, I did not get access to birth control pills or institutional delivery. But my daughters are fortunate that they can have control over their bodies and could go for safe delivery. I convinced my son-in-law and daughter to approach the ASHA worker of our village in order to get the tubectomy done. After all, it’s my daughter who will have to bear the burden of repeated childbirths,” she says.