NEW DELHI: Some 3,000 Accredited Social Health Activists and Urban Social Health Activists employed by the Madhya Pradesh government gathered in Bhopal’s Polytechnic Chowk last week, on October 2 and 3, demanding a fixed minimum salary for their work.

The workers had come to Bhopal from 16 districts across M.P. At a distance of 200 metres from Chief Minister Shivraj Singh Chouhan’s residence, according to reports, they were set upon by policemen and women, who beat them with lathis, prevented them from going any further, and forced over 100 of the workers into police vans and driven to the Central Jail, including one of their children, a 5-year-old boy. They were not informed where they were being taken. Some of the workers reportedly hit back at police.

One of the ASHA workers, Laxmi Kaurav, who is also a community correspondent for the media website Video Volunteers, posted this video:

One of Kaurav’s colleagues, ASHA worker Mamta Rajawat, was seriously injured as police tried to force her down from a mobile phone tower which she had climbed during the protest, for reasons unknown. According to another video commentary sent in by Kaurav, she accompanied Rajawat to hospital and stayed there the night, until Rajawat had regained consciousness.

According to Amrita Anand, a Video Volunteers representative The Citizen spoke to, police have now filed a case against Laxmi Kaurav and five other ASHA workers. They have not been told the nature of the allegations, and were only able to discover the complaint number. Mamta Rajawat remains in hospital, though her colleagues have been visiting her and providing her with the things she needs.

ASHA and USHA workers in Madhya Pradesh have been protesting since April this year. According to Anand they even met the chief minister, who promised them the government would do something to address their demands. Says Anand, "Without rural health workers, the public health system would collapse. These are the same workers whose contributions are cited by Prime Minister Narendra Modi in his speeches. Yet they are treated poorly, and don't want to be treated this way. They want the respect due them for the work they are doing."

In the short video below, an unidentified ASHA mobiliser at the October protest lists the workers’ demands:

These health workers in Madhya Pradesh are asking why the national statutory minimum wage of Rs 18,000 per month doesn’t apply to them. They are demanding Rs 10,000 per month for ASHA-USHA workers and Rs 25,000 per month for ASHA sahayoginis, who monitor and coordinate the health services provided by ASHA workers in an area.

According to the Union Ministry of Health and Family Welfare’s (MHFW) own assessment, Accredited Social Health Activists are the first point of contact for medical care for people in many villages. As the unidentified ASHA worker explains above, like other government staff these workers too need a travel allowance, as their work involves extensive travel in the field, and rising petrol prices affect them as well.

Ironically, an MHFW report published in July 2017 raises exactly the same concerns, admitting that “High costs of travel, poor communications and lack of physical accessibility to the villages and health centres emerged as a challenge for both the ASHAs and the ASHA mobilisers.”

The report adds, “ASHAs face issues in opening of bank accounts and even withdrawal of money because of poor accessibility to banking services. Aadhaar cards were provided only at the district headquarters, and ASHAs who were not able to travel the distance were not able to get the card. The recent rule of making payment to bank accounts linked with Aadhaar, has further made it difficult for ASHAs to receive timely payments.”

The protesting health workers whom police were ordered to attack in Bhopal were raising the same demands. As the unidentified ASHA worker told the media, “Let us do our work. We are called on Sundays, on Diwali. Give us a fixed work schedule and fixed pay. And guarantee our security.” However, Chief Minister Chouhan did not meet the protesting workers, nor acknowledge their demands.

With central health spending a more or less stagnant 1.3% of GDP for the past decade, as compared to a world average of 6%, the limited public expenditure on healthcare is increasingly being borne by the states, which now account for three-quarters of total public health expenditure. According to the latest available figures, the number of ASHA and USHA workers has been declining, and stands at 8.77 lakh nationwide, despite the states increasing their combined target to 10.21 lakh workers.

Madhya Pradesh is a “high focus” state under the National Health Mission, with urgent healthcare needs. A NITI Aayog report last year said that such low-income states tend to spend a significantly lower proportion on social services such as health. According to this year’s Economic Survey, a five-year decline in real terms in the central expenditure on health was reversed this year, with a nominal increase of 23% in the budgeted amount. The truth of this remains to be seen; at present the Indian government spends about Rs 3 per day per citizen on healthcare.

The ruling Bharatiya Janata Party’s election manifesto in 2014 promised to reduce Indian families’ out-of-pocket spending on health. A 2015 study found that 8 out of 100 Indians had been pushed below the poverty line in the past year because of medical expenses, about half of which go into buying medicines, and a fifth on treatment and diagnostic tests at private hospitals.

In Madhya Pradesh the average ASHA worker may earn between Rs 800 and 1000 per month, as their remuneration is linked entirely to their activities: for instance they will be paid Rs 250 for nine months' antenatal care resulting in an institutional delivery. Most other states provide a fixed honorarium above such “incentives”, or match them, ensuring a minimum salary for these health workers.

Nevertheless, reports suggest that in the past three years India has seen protests by ASHA and USHA workers across 17 states, and their main demand has been for regularisation: a fixed salary, fixed hours, and coverage for health and travel expenses.

The average ASHA worker in India is responsible for about 900 people. Depending on the area, their work includes: ante and postnatal monitoring and counselling; basic treatments such as ORS, folic acid tablets and anti-malarial medications and nets; dispensing condoms and awareness about contraception and STIs; sanitation awareness; ensuring child immunisation and infant nutrition; screening for cataracts, and for noncommunicable diseases like diabetes, hypertension, and oral, breast and cervical cancers.

The infant mortality rate in India is 37.8 per 1000 live births, and the maternal mortality ratio 130 per 100,000. The OECD average is 3.9 and 12 respectively. In M.P. the figures are 47 and 137 respectively.

Last year the Madhya Pradesh government spent just 4% of its money earned from the public on healthcare, reflecting a nominal increase of 8% over the previous year, according to a report by PRS Legislative Research. The latest budget promises a nearly 20% increase.

Elections in Madhya Pradesh will be held on November 28. The Election Commission's model code of conduct took effect on October 6.