The cases of four ASHAs are presented under two broad categories: (1) challenges of ASHAs in providing health services and (2) post-conflict vulnerabilities of ASHAs as women residing in conflict-affected communities. In most cases, the ASHAs we spoke noted that their experiences were common to other ASHAs working in conflict-affected areas.
Challenges of ASHAs in ensuring access to health services
Transportation difficulties
In our discussions, ASHAs noted that during the conflict, the main challenges were poor transport linkages and communication. One worker, Sarita [name changed], pointed out the great difficulty faced by all ASHAs when the drivers of 108 emergency or 102 ambulatory services (implemented by the State National Health Mission) would refuse services and the family members of the pregnant woman would expect the ASHA to arrange transportation.
Figure 1 describes challenges faced by Sarita, as narrated by her, during the conflict where the family members of a pregnant woman approached and informed her that labour pain had started. She went with them and saw that the woman was in pain. Sarita immediately called 108 ambulance services but they refused to send a vehicle and asked her to make other arrangements. She even tried contacting drivers of private vehicles in the village but they too refused. In the meantime, she contacted the Community Health Officer at the sub-center (SC) and Medical Officer (In-charge) at the Primary Health Center (PHC) but they too could not help her. With no option left, the delivery was conducted at home: the woman suffered pain for two days and gave birth to a stillborn.
This difficulty in arranging transportation remained even months after the conflict episode and was reportedly due to pervasive fear among the drivers – both in the public and private sectors - of being stopped and beaten by army personnel. Another such instance was shared by Sarita where she had to take a pregnant woman 15 days after the conflict had ended. That day, both 108 emergency service and 102 ambulances refused. She tried contacting private vehicles and luckily one auto-driver agreed to drive them to the health facility. However, while returning, as the driver was alone, army personnel stopped and beat him up for driving at the time of conflict. Because of this incident, the drivers were afraid and one auto-driver placed a condition that he would take pregnant woman only if Sarita returned with him and did not stay in the health facility along with the pregnant woman. This condition placed her in a dilemma as the health system expected her to be present during delivery and if she were to refuse the driver, this would affect his willingness to transport this and other pregnant women in the future.
She further noted that the situation after conflict remained volatile for a few weeks, but she had accompanied pregnant women to the health facility for delivery by ignoring her fear: “we had to take them [pregnant women] even if we were scared to travel on the road as we had no other options.”
Another challenge during the conflict was the breakdown of health services at the peripheral health facilities such as SC and PHC providing primary health care. Many times, ASHAs were left with the option of accessing the district hospital, which was already far away from their village and all the more difficult to reach at the time of conflict.
We found that there was no support mechanism to ease the difficulty faced by ASHAs in ensuring access to health facilities during the conflict. It was left to ASHAs to arrange transportation for reaching the health facility. We noted that their challenges remained unaddressed.
Another ASHA, Junali [name changed] noted that she had been displaced from her native village, but was still covering 10 households in that location (she is formally listed as the ASHA from this village) and the areas where the people were residing after displacement. She noted that the distance affected her performance as she had to visit three places to mobilize communities for immunization and other services.
Unpaid labour
Anita [name changed] noted that at the time of conflict she was engaged in a relief camp and supported the health staff in providing health services. According to her, all staff including ASHAs were expected to be available to provide services in relief camps, but there was no provision to pay for the work done by her and other ASHAs. She felt that it was her duty to provide health services; but also noted that she knew that the health system had funds for her work, but did not provide compensation. There was a feeling that ASHAs labour was not recognized.
“We have to be bold and leave our home and family to help them [health system]. The Sir's [doctors and district health officials] only tell us to do the work but don't think about us even once. They need to look at our pain and problems…We work so hard at the relief camps, leaving our home and families, for such a long time. Even if we are afraid, we have to be bold and yet we don't get any incentives or salary. We are expected to do the work for free. But we don't back out and do our jobs as soon as we get our orders [from health officials].”
Physical safety and security
A common concern was over the safety of ASHAs and other frontline female health workers such as Auxiliary Nurse Midwives during the conflict. They were expected to reach the relief camps or place of duty on their own. Although Anita reported working amidst fear, there was no denying that with no provision to ensure safety, ASHAs were vulnerable to violence and their security was a threat. This was corroborated by Junali who expressed her concern about returning home alone after completing the work at a health facility.
“You understand sister, some of our women are in XY village...some in YY [name of the villages anonymised]. The way we live in the village, we feel scared when we accompany [pregnant women] for delivery and then we have to go the [health facility] office, how will I come [home] alone.”
Even as drivers and others felt that ASHAs would shield them from violence meted out by army personnel, this placed additional burdens on ASHAs and was not always the case.
Community trust and acceptance
We found that ethnic conflict in both the districts had broken the social fabric in the community, in turn affecting ASHAs and their performance. Non-acceptance of ASHAs belonging to opposing ethnic communities was an articulated concern, particularly when the population catered by ASHA comprised of people belonging to a different ethnic community. Even though ASHAs did not mention their fear specifically, it was evident during the discussion that there was hesitation to visit hamlets belonging to certain communities, particularly when ASHA and the villagers belonged to conflicting communities.
Sarita noted that women belonging to other communities were inhibited in reaching to her for health advice although her community was not involved in the conflict. She further mentioned that those affected – the Bengali Muslim community - believed that her community conspired with the Bodo community in burning their houses. As a result, she noted, this community stopped trusting her. It is noteworthy to mention that ASHAs were also vulnerable to the hostile attitudes of the community and faced threats when the trust was lost between communities.
“It affected me as [Bengali speaking] Muslims did not believe me. The conflict was between Bodo and Muslim communities but the Muslim thought that my community was also involved in burning their houses. They kept to themselves and stopped coming to me for pregnancy care. The young Muslim boys were furious during the time of conflict and they tried to threaten me but I calmly explained to them. Now things have improved and Muslims in my area love me.”
Notwithstanding the above, it’s important to note that the inhibition and lack of trust were declining, especially in areas where there had been a long period of relative peace. This was mentioned by ASHAs and also observed during our fieldwork. We observed at the time of interview that women belonging to the Bengali speaking Muslim community visited Sarita at her home.
Vulnerabilities faced by ASHAs experiencing conflict
Loss of family members
We found that ASHAs had experienced conflict much the same way the community did. Their family members were killed, injured, tortured, or went missing, while others experienced psychosocial distress. ASHAs also suffered the effects of conflict during and after due to resource depletion and dislocation, just as other members of their communities.
One ASHA, Jennifer [name changed] lost her husband in conflict as he went missing. According to Jennifer, her husband and other men from the community were attending a peace meeting when the ethnic conflict started. She and her two daughters and sister-in-law were alone at home when they got to know about the conflict. Her youngest daughter was a week old new-born. Her daughters, sister-in-law and she ran for their lives and reached the first of many relief camps, never able to return home for fear of further violence.
While narrating her experience, Jennifer mentioned that “I took her [youngest daughter] for some time and I was unable to run properly and my elder daughter was also running. Everyone in our family ran and I was left behind. My sister-in-law helped me and took her [youngest daughter]. We stayed the night at XX [place and camp name withheld]. Her father [Jennifer’s husband] didn't come and we couldn't find him. We lost all our property and land. I stayed near the camp area and never returned home.”
Displacement
We found that internal displacement – temporary or permanent- during the conflict was experienced by ASHAs. Displacement had significantly affected their living conditions, particularly among ASHAs in Kokrajhar district. As they had experienced repetitive conflict since the 1990s. Like for other members of the community, displacement due to the conflict had led to the loss of farmland, livestock, and occupation of their family members. Jennifer, for example, had suffered permanent displacement after she decided to stay back in the area where relief camp was established as she believed that the current place was more secure than her native village.
Similarly, Junali [name changed] and her family were internally displaced multiple times since 1996. Figure 2 summarizes the repeated displacement from 1996 until 2005. Junali noted that after the first conflict in 1996 her family stayed in a relief camp near block headquarters for one year before returning to the native village in 1998. After staying for a year in the village, they were again displaced for seven years. She and her family stayed in a relief camp. Out of fear of displacement, her family bought a plot in the area close by to the relief camp but returned to their native village in 2005. However, in 2012, another round of conflict occurred and they had to leave their village again. The family decided to stay back and built a house in the newly purchased plot. Junali informed that almost all natives of her village had left their village and were staying in villages close by to her current residence.
Job Insecurity
At the time of the interview, Jennifer was supporting her youngest daughter’s education by working as an ASHA and operating a small shop in the village. She had also adopted an orphaned boy whom she found in one of the relief camps. Being the only earning member of the family, Jennifer was in fear of losing her job because households in her area were opting for family planning, hence there were fewer pregnant women compared to other villages. Given the thrust on institutional deliveries under a conditional cash transfer scheme known as Janani Suraksha Yojana, this incentive per pregnant woman was the main source of incentive for ASHAs. Jennifer who joined as ASHA in 2008, was afraid of losing her incentives and even worse, her job altogether:
“Now, I am working as an ASHA. What is ASHA's salary? And there are no pregnant women in my area ma'am. Income is there in an area where pregnant women are there. The Government is asking to leave but where will I find another job?”
We found that ASHAs in Kokrajhar were living in constant fear and insecurity. We observed that the health system was concerned about ASHAs performance in terms of rendering health services, meeting the planned targets, and being available whenever called for duty. We did not see, on the part of the health system, an investment in understanding or addressing the challenges and vulnerabilities faced by ASHAs as health workers and community members, even as these would directly affect their performance and the envisioned targets of the health system.