Over the many years that I studied in academic institutions, I spent a great deal of time attending workshops and perusing textual resources to understand strategies on how to reach the last mile in any social policy or intervention. While these resources were useful in their ways, the past few months gave me the opportunity to learn this from the frontline workers of India’s health system.
Across India’s vast and diverse landscape, Accredited Social Health Activists (ASHA) function as the bridge between the government health system and the community. Along with the Auxiliary Nurse Midwife (ANM) and Anganwadi worker, they form the backbone of the community’s health landscape, especially in rural areas. These women are community leaders who play a cardinal role in ensuring the health and well-being of the village.
As part of my fellowship project, we undertook a pilot intervention in a village in Shahdol to understand the status of health governance at the Panchayat level. An important first step to designing an effective intervention program is acquainting ourselves with the community and the geography of the village. Over several days, we conducted transect walks in the four ASHA areas within the village. Transect walk is a widely used methodology to observe and understand the infrastructure, patterns of settlements, livelihood, natural resources etc of a geographical area. This is a guided walk with community members where the visitor acquaints themselves with the community and the place through questions and discussions. Our objective for these walks was threefold. First, to understand how the ASHA covered her designated geography on foot. Second, to gauge the community’s accessibility to health institutions/services such as Anganwadis and ambulances and third, to learn the ASHA’s perception of her work, the hurdles and the rewards of it.
Covering each area took us several hours. Every pocket within the village had a social, economic and cultural context that was unique to it. Geography is inevitably an important factor that shapes not just cultures and livelihoods but also people’s access to opportunities and markets. The area around the Panchayat and the pucca roads had populations that were much better off. As the distance from these modern signs of development increased, so did the hardships in accessing a healthy life. Houses located at the outskirts, interspersed with fields, had routes that could only be traversed by foot. While in certain cases people found ingenious ways to subvert these difficulties, in others it became a disabling factor that restricted access to institutions. As we walked, the ASHA recounted a story of one pregnant woman who delivered her baby on the road while she was walking from her home to the main road to reach the ambulance. Stories like these weren’t uncommon in areas with such topography.
In mapping the different mohallas (pockets/ smaller areas), ASHA areas and the village itself, we were trying to gradually build our knowledge of the communities and geographies being left behind by government services and policies. Walking with the ASHA and listening to her everyday schedule that aimed to ensure that she caters to the well-being of her community, her strategies of reaching the last mile became an important learning opportunity.
Every ASHA area had pockets or geographies that weren’t traversable to her by foot or alone. These could be a cluster of houses that were situated inside the forest or on the outskirts of the village beyond agricultural fields. Instead of leaving them behind, she often took support from the male members of her family to reach these places. In many cases, it was clear that being an ASHA wasn’t just the occupation of the woman who was appointed as an ASHA by the government, but it was also a responsibility that extended to her entire family. At times when this support wasn’t available, a mobile phone, a friendly neighbour or an important community influencer became the tool that connected the last person in the village to the Anganwadi and health services.
While working closely with ASHA workers over the past few months, I have observed the firm resolve with which they approach their work. This certainly isn’t an attempt at an exaggerated glorification that paints frontline workers as larger-than-life characters. Their work is important but also littered with several obstacles they face on an everyday basis. These are posed by geography, unjust community practices, stagnant systems, low and irregular remuneration etc. Therefore, it becomes necessary to move beyond a mere acknowledgement of their efforts to take concrete steps in improving their working conditions. Focusing on ensuring regular remuneration and spaces for grievance redressal are the first steps towards the same. These are provisions that the present system is struggling to make.
For those of us trying to constantly ensure equal representation and participation of all communities across different spheres, walks like these are an important reminder. These individuals working tirelessly as the bridge and backbone of a village’s health needs, have perfected mechanisms in their own capacities to ensure that the right to quality healthcare reaches the last person. These frontline workers and their constant attempts to reach the last mile offer an important lesson on how to make the extra effort to serve our communities better.
