Gizala Shabnam
A giant hoarding frames the quintessential picture of India’s polio campaign: an infant being administered polio drops. Another hoarding facing it has a cheerful sketch of a mother and a newborn, depicting the activities of community health workers. These hoardings all across the country highlight the Government’s efforts at making universal health a reality for all. So too, is the intent of these hoardings installed at the entrance of the District Hospital, Kargil. The stream of patients going in and out of the hospital in this small mountainous town at India’s sensitive northern border is rather oblivious to the information beaming down at them from the hoarding. But, as one drives a few miles outsideKargil town, the attempt to spread awareness is virtually foiled by the daunting distances. Locked health centres and uninformed villagers tell a completely different tale.
Kargil, the infamous ground for the 1999 war between India and Pakistan, two hundred and thirteen kilometres from Srinagar, remained in its own cocoon till the breakout of the conflict that gave it national attention. Soon after the war, the focus shifted towards the long ignored people of this district tucked away in Ladakh province in the northernmost Indian State of Jammu and Kashmir. Sure, it did connect Kargil with the outer world, helping them, at the very least, to put forth the difficulties they had been facing all these years. The Kargilis welcomed education, health and employment reforms. These, in turn, ushered more complexities.
As far as health was concerned, in the earlier times, traditional therapies and recipes were sufficient to help one lead a healthy life. But the post-war era induced more complex and advanced medical amenities.
The well-intentioned decision makers wasted no time providing for a number of health policies and schemes. The NRHM (National Rural Health Mission), launched on 12th April 2005 by the Government of India, sought to provide effective health care to the rural population. With its prime emphasis on women and children, one of the major projects of the NRHM was to provide every village with a trained female community health activist – Accredited Social Health Activist (ASHA). The ASHA initiative sought to ensure an inclusive growth by enveloping every single village.
In Kargil, ASHAs were employed in each of its 129 villages (9 Blocks) that expected to bring a significant improvement in the healthcare sector. In line with the program’s mandate, the ASHA workers selected in Kargil were entrusted with the responsibility of promoting healthy behaviour and mobilizing communities to utilise public health services. Selected from the village itself and accountable to it, the ASHAs were trained to serve as an interface between the community and the public health system. Apart from the primary role of registering and encouraging women to avail institutional delivery, these health activists were assigned the task of counselling their community on birth preparedness, safe delivery, feeding practices, immunisation, vaccination and feeding practices and ensuring that these are practically followed which in turn grants them some incentives.
However, despite the Kargil Government’s effort to implement this evenly, the advancement of ASHA in Kargil sadly appears highly asymmetrical. Though villages near the main town areas continue to be scrutinised well by the healthcare facility, remote areas are benefited only tangentially and hence remain underserved.
The blame for the situation is shared equally by the healthcare department and the villagers.
Unlike ANM (Auxiliary Nurse Midwife) and AWW (Anganwadi worker), ASHAs are not paid fixed salaries under NRHM but receive performance-based remuneration as motivation. Every ASHA is entitled to receive an amount of Six Hundred Rupees for assisting delivery in any Government identified institution under JSY (JananiSurakhsaYojana). There are fixed incentives also for immunisation/vaccination and for motivating family planning. These promised incentives are a major motivating factor for the ASHAs which, when refused, tend to affect their performances. Over the years, their incentives are either deducted to lower sums, delayed or completely done away with.
NargisBano, an ASHA worker employed in Village Karpokhar located fifty five kilometres from Kargil town was initially paid Six HundredRupees for assisting deliveries, which has now been reduced to almost half the initial amount. Zahra Batool from KartseKhar village and SadiqaBano from Bartso village deny getting any incentives for vaccination and immunization for the last two years. The performance based salary of the ASHA workers has made them dependent on the community members who they assist and direct. “Despite several efforts to make them aware of benefits of having deliveries in hospitals, incentives and care offered under this scheme, many villagers do not reciprocate well,” rues Fatima Bano.
Some of the pregnant women avoid informing these ASHAS as they deem the whole process too voyeuristic. Apart from the scarce incentives and a reticent public, the performance of these ASHAs is also deterred by the nonchalant attitude of the healthcare authorities.
Once appointed, ASHAs in these remote areas are not paid due attention. Regular replenishment of ASHA kit is not dealt with carefully, which leaves many of them with nothing to offer their patients in case of an emergency. The training sessions are highly irregular. As opposed to the prescribed 23 days trainings, most ASHAs have not been trained for more than a week. Most of the time, there are no trainers available.
HakimaBano, an ASHA worker from Apatte (23 km from Kargil), has driven many a times all the way to town, only to find the trainers missing. Sakina Bano from Thasgam (23km from Drass district) too feelsdissatisfied for the same reasons. However, areas that lie at a stone’s throw distance from the town have another story to share. They flaunt a pretty impressive ASHA record. ASHAs from major blocks – Trespone, Shargole and other nearby villages – a vow that their job is very respectable and a great source of income, earning them status and respect from the community. Many ASHA workers feel that the reason behind the disparity lies in reaching out to the communities located in inaccessible parts of Kargil. Extra efforts should be invested in making them aware about the benefits of such schemes and cater to their needs on time.
It is clear that, as long as the far flung areas of Kargilremain underserved, the NRHM’s prime objective of inclusive growth will remain unmet. This chequered status of women’s healthcare in Kargil clearly reveals the casual outlook of the appointed authorities and calls for a strict and cautious regulation to ensure its effective implementation that guarantees evenly benefits to all.
Charkha Features
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