Breakwater of Karnataka's rural Covid wave

ASHAs, along with other frontline workers, are the foot soldiers in the fight against surging cases of Covid in rural areas

The state government’s decision to discontinue home isolation is a source of both relief and concern for Rajeshwari, an Accredited Social Health Activist (ASHA) in Kurugodu taluk of Ballari district in Karnataka.

As per yesterday’s announcement, Covid-positive patients will be shifted to Covid care centres, which means Rajeshwari doesn’t have to check their oxygen saturation levels everyday. “Even though I used to sanitise the device after every use, repeat use by multiple persons had proved to be a challenge.”

But then, life won’t change much for her.

She still has to visit primary contacts in their homes and deal with people showing Covid-19 symptoms during the survey on influenza-like illness (ILI), for which she visits 50 houses every day. Mobilising people for vaccination is another task she has to attend to.

There’s more.

From recording the vitals of the vulnerable population, listening to their concerns about hospitalisation to persuading those with Covid symptoms to get the test done, she spends most of the day interacting with people.

Also read; Steady decline in daily Covid cases in Bengaluru; Karnataka logs over 41K cases

All the while, she feels that there are much more Covid-affected people who are not diagnosed yet. In her district, Ballari, roughly four in 10 tested are turning positive already.

During the rest of the day and sometimes, even at night, she attends to the needs of pregnant women, women in postnatal care, children and those who are severely sick.

Equipped with just a cloth mask, a sanitiser bottle, a pulse oximeter and Covid-19-related information she has gathered from different sources over the past year, Rajeshwari tries her best to protect herself and over 250 households in her care.

“Every time I try to clear their doubt or address a fear, I realise how underprepared I am. Everything is so confusing. Will I be able to protect people or end up losing their trust?” she asks.

Like Rajeshwari, around 42,000 ASHAs, who are the face of the public healthcare system in the villages and effectively the first point of contact for lakhs of people seeking medical attention, are feeling helpless.

ASHAs, along with anganwadi teachers, health assistants, staff nurses, primary health centre doctors, and in some places, mid-level health providers, are the foot soldiers in the fight against surging cases of Covid-19 in rural areas. On May 13, 65.7 per cent Covid cases in the state were reported from outside Bengaluru.

While experts say that the Covid situation in rural areas is a ticking bomb, the ones who can save people from this crisis are feeling defenceless due to the lack of evidence-based information about Covid, their lack of training in counselling and more importantly, a perceived disregard for their work.

The government’s hasty and flawed decisions and urban-centric Covid response have only added to their woes.

Read | Home isolation discontinued in rural Karnataka to prevent spread of Covid-19

Rajeshwari feels that the government’s decision to end home isolation without setting up enough facilities might further scare people. “Now only 15 per cent of people agree to get the test done after several rounds of counselling. Clearly, they are scared of the implications of being tested positive — from losing livelihoods to fearing for their life itself. Recent developments have made them lose faith in hospitals,” she rues.

Her apprehension is not without a reason: The local administration had called applications to hire 75 doctors to serve at the temporary Covid hospital that is being set up in Toranagallu with a capacity of 1,000 oxygenated beds.

They received only one application.

Similarly, they haven’t got sufficient applications for the posts of nurses, lab technicians and pharmacists.

The situation is no different in the ‘developed’ southern parts.

The Hanchya primary health centre (PHC) in Mysuru district covers a population of over 22,000 people. One doctor (who manages both Covid and non-Covid duty), 3 junior health assistants, 17 ASHAs, one lab technician and one Group D staff pull off the show. This PHC is one of the Covid Mitra centres in the district, which is catering to the different needs of people — from screening to prescription and advice on hospitalisation.

Also read: Steroids, diabetes main causes of black fungal infections in Covid patients

Experts believe that ASHAs, anganwadi workers and health assistants can help tackle this grim situation of a lack of trained medical professionals in rural areas.

And they are holding firm against all odds, through sheer grit and determination.

“I learnt to drive a two-wheeler during last year’s lockdown as I had to visit the villages everyday and there was no transportation. This has come handy this year,” says Arogya Mary, a junior health assistant in Ballari district.

However, the frontline workers are not satisfied with the government support.

Government apathy

Nagalakshmi, State Secretary of ASHA Workers Union in Karnataka says ASHAs are exposed to Covid-19 with little protection. “As a result, 25 to 40 ASHAs in each district are infected. Five of them have died in the second wave. The families have not got any compensation so far,” she says.

Mysuru-based physician and public policy advocate Dr R Balasubramaniam feels the government’s decision on home isolation is uni-dimensional. He says that if implemented effectively, home isolation is a good, practical and cost-effective approach.

“The rural response to Covid very much involves families. Capacity building of ASHAs, anganwadi workers and junior health assistants in Covid prevention and management techniques and home isolation requirements like proning, and creating a strong support system are crucial to tackle the pandemic,” he says.

What angers him is the government’s apathy towards health workers in providing quality protective gear, special treatment when infected (for the frontline workers and their family), and financial support and insurance to the family of the deceased.

Health activist Teena Xavier, who works in North Karnataka, has been interacting with health workers and the district administration of Vijayapura with an aim to form a support system.

She says the lack of information is a major hurdle. “A helpline which provides all required information at one go without redirecting you to several other helplines will empower the health workers to facilitate necessary treatment for the Covid-affected,” she says.

Currently, the role of ASHAs is limited to informing junior health assistants or doctors, who in turn check with the nodal agency for necessary action. Enabling ASHAs to carry out this task will help in many ways. But they are just told to do certain tasks without proper information or training.

Information and transparency

With quick test results, responsible information dissemination and transparency, over 80 per cent of the cases can be treated at home, says Dr Sanjeev Kulkarni, a Dharwad-based practitioner.

He says the most urgent step the government needs to take is making the information on oxygen, bed, ventilator and essential medicine stocks at different facilities available at the grassroots so that people can make informed decisions

Also read: Overall Covid-19 situation stabilising in India: Centre

An ASHA in Kodagu district shares her harrowing experience of travelling more than six hours to Mangaluru to get Covid treatment when she developed breathing difficulty. Her children arranged for her treatment in Mangaluru, when there was no one locally to guide her to a well-equipped health facility in Kodagu.

The workload of frontline workers has increased multifold. A doctor on Covid duty in North Karnataka, who did not wish to be named, says that the healthcare staff don’t get themselves tested regularly even though it is advised. Staff shortage doesn’t allow them to take a 14-day break from work in case of a positive result.

“We opt for testing only when there are symptoms,” he says.

“They have deputed medical students on duty in the district hospital. We have no information on availing their services in primary or community health centres,” he says.

They soldier on

Many of these frontline warriors face the ire of people who are distressed by the current situation, with several cases of abuse being reported from across the state.

“We have successfully implemented several programmes in the past. People have always respected us. But this time, they don’t have the same kind of confidence in us. They repeatedly ignore the norms and blame us for any eventuality. Two months back, they doubted the motives behind vaccination, now it is testing,” says Nalinakshi, an anganwadi worker in Doddaballapura.

“ASHAs, anganwadi workers and junior health assistants are the most vulnerable and they suffer silently, without any acknowledgement of their work,” says Mamatha, a rights activist and Covid volunteer in Anekal.

She has seen people from Bengaluru thronging the vaccination centre in Anekal, snatching the share of the rural people who are not digital literate. This hurts villagers who in turn blame the health workers.

Health Minister Sudhakar K had recently said that the government is working hard to strengthen infrastructure at the taluk-level hospitals. While such measures are crucial for tackling Covid, the government should understand that empowering the first response team is equally important.

Till then, ASHAs, anganwadi workers and health assistants stay the course despite knowing the fault lines.

The incentive puzzle

ASHAs, recruited in Karnataka as part of the National Health Mission starting from 2008, are considered voluntary health activists. Since they are not employees, they don’t get a salary.

While they get a fixed incentive of Rs 4,000 per month from the state, the Centre provides an honorarium of Rs 2,000. However, 50 per cent of the ASHAs don’t get the full amount of Rs 2,000 due to several reasons, including technical glitches.

Then there is a performance-based incentive which is dependent on various factors including the tech-savviness of the junior health assistant who uploads the monthly report of the ASHA.

The total budget allocation for them is Rs 10,000 but a majority of them get around Rs 6,000.

They are used to the inordinate delay in payments and they acknowledge that for one year during Covid-19, they got their payments every month along with a Covid incentive. However, now they have been waiting for their payments for the past two months. To end the uncertainties, they have been demanding a fixed payment of Rs 12,000 per month.

Last July, Annapurna, from Tunganagar in Shivamogga town became famous when the Central Government mentioned her name in a tweet lauding ASHA workers' tireless efforts in fighting Covid-19. Admiration and gratitude are not new for ASHA workers.

"We are doing whatever work is assigned to us. They can acknowledge our work by fixing a monthly payment so we don’t have to worry about it," says this single parent who has to take care of her mother and daughter.

She covers around 15 families every day walking 7-8 kilometres: starting from pregnant women, women in postnatal care and toddlers, she then moves to Covid-affected households checking on their health, giving them required medicines and keeping a watch on primary and secondary contacts for any symptoms etc.

The love and trust of the 2,000-odd people that depend on her keeps her going, even at the cost of constant uncertainty.

In Bengaluru, Amitha faces constant pressure from her family to quit her job. “My husband and mother-in-law think that I am a fool to put myself at risk for whatever little money I get, that too like a lottery. Now my neighbours also support them as they fear I might spread corona," says the mother of two toddlers.