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  • Kerala model: When the frontline is backbone

ASHA workers on their rounds

Kerala model: When the frontline is backbone

Vandana Puthezhath, Thiruvananthapuram

Published: Jun. 18, 2021
Updated: Jun. 19, 2021

VEHICLES scattered left and right as Ushakumari S., surreally perched on her scooter in a personal protective equipment (PPE) suit, drove at top speed through Kollam’s streets to get to a hospital.

Riding pillion with her was a COVID-19 patient, Ramla Beevi, who needed her second antigen test done. Ushakumari had got fed up, waiting for an ambulance to ship the patient, and decided to take matters into her own hands.

“It was quite a sight to see people and vehicles on the crowded street make way for my scooter,” recalls Ushakumari, who is in her late forties, with a smile.

Elsewhere in Udduki a no less important feat was pulled off with equal urgency. Ambili Chacko of Vandipperiyar attended to deliveries within the span of a few hours in the middle of the pandemic with no transport available. One of the deliveries was in a tribal hamlet. Chacko made it a point to show up and two precious lives were safely brought into the world.

Apart from their diligence and public spiritedness, what both women have in common is that they are Accredited Social Health Activists or ASHAs under the National Rural Health Mission (NRHM) launched by Prime Minister Manmohan Singh in 2005.

ASHAs are meant to create awareness and there is one for every village. States like Kerala which have integrated ASHAs well into the healthcare system have benefited during the COVID-19 pandemic. ASHAs have been on hand to counsel patients, get them to health centres and hospitals, and provide general services like midwifery when the rest of the healthcare system has been overtaken by COVID-19.

Kerala’s public healthcare model has been lauded the world over. During the pandemic, health minister K.K. Shailaja led the crusade against the novel coronavirus from the front, putting in place efficient systems for tracking the spread of the virus, for testing, quarantining and ensuring timely and low-cost medical care. She became a role model and a hero, in India and abroad.

Kerala has an integrated public health system which the state has invested in over the years. Primary health centres (PHCs) and community health centres (CHCs) are linked to secondary hospitals which are connected to general hospitals and medical college hospitals. Private healthcare has been rising in popularity but during the pandemic both have been working together.

What also distinguishes Kerala’s healthcare system is compassion and kindly care. Social distancing, masking and quarantine require a gentle touch. And it begins with the ASHA worker ringing your doorbell with a cloth bag on her shoulder and a smile.

Kerala has more than 26,000 ASHA workers. They had a tough time initially when the pandemic first struck. People worried about life in solitude, they were anxious about their near and dear ones. They feared the reaction of people if they came to know they were infected.

So in the early days of the crisis, people would not cooperate with ASHA workers. But as the virus began infecting larger numbers of people, fear of social ostracism began to diminish.

“Initially, we faced resistance and emotional outbursts when we would go to put up information stickers telling people about COVID-19 patients or quarantined residents. We tried to calm them down and carry on with our duties. We used to walk a lot to visit houses and to provide medicines and essentials,” says Priya, an ASHA worker in Thiruvananthapuram.

“As the pandemic went on and normal life stood at a standstill, we started to receive more support. People warmed to us and started to appreciate our efforts,” she says.

Antony, a COVID-19 patient in Vattiyurkavu, a neighbourhood in Thiruvananthapuram, fondly remembers the ASHA worker of his area.

“I had no major symptoms and was generally healthy, so I was advised to quarantine in my house. I can’t find words to thank Thankam, the ASHA worker of my area,” he recalls. “She not only ensured my supply of medicines, she called me many times to enquire about my health. The way she reassured my worried wife and comforted my young children who were really anxious because they couldn’t see me, she really was a blessing.”

Thankam merely smiles at all the compliments. She says she is happy to have done her job well. She has no time to lose. She still has many houses under her jurisdiction to visit to ensure all home isolation patients are taken care of.

“We go door-to-door. When we are at one end, we may get a call asking us to come to a home at the other end. We attend urgent calls with the fastest response possible. Actually we feel that we get more calls and are busier than even the administrators. Jokes apart, we know the importance of our job. We are the first in the line of defence,” says Bindu, an ASHA worker in Thiruvananthapuram.

ASHA workers are paid poorly — around `8,000 per month — compared to the work they do. A hike in honorarium of `1,000 from March has yet to be implemented. “But when patients express their gratitude with tears in their eyes, it makes it all worthwhile for us. We know we are doing our job and that our contribution isn’t a small one,” says Aparna from Kozhikode. 

The women also have to protect themselves. “There is a constant sense of fear as we work closely with patients and those in quarantine. I enter my home only after having a bath and washing my clothes outside. But we are always ready for the next day with a smile on our faces. We know that reassurance means a lot to those who are sick and alone,” says Sini, who is from Kollam.

With their meagre salary ASHA workers don’t have much to spare. Despite that, some of them generously bought essentials for people who were poorer than them. They also delivered babies because many women didn’t have money to get to a hospital.

Another notable achievement of ASHA workers is their meticulous collection of data.The success of the state’s trace-test-isolate-support strategy owes a lot to them. Senior health officials admit that the ASHA workers played a key role in alerting local bodies and health departments about suspected cases and ensuring home quarantine.

The success of Kerala’s health model is also due to its battalion of experienced nurses. The Malayali nursing community is well-known across India’s medical circles and globally.

“Nursing is the noble profession I chose for myself, so why would I worry,” says Sandhya, who works at the Thrissur Medical College where India’s first COVID case was treated. “I experienced the Nipah outbreak too so the PPE suit was not a new thing for me.”

Medical services were also buttressed by the efforts of Kudumbashree units — self-help groups of women across the state. Patients confined in PHCs and Covid First Line Treatment Centres (CFLTCs) during quarantine particularly thank them. They cooked hundreds of meals for them.


P.A. Kishor was in a CFLTC  and says, “I missed home terribly. I hated being alone. But I didn’t miss home food. I got breakfast, lunch and dinner with all the flavour of home.” Hundreds of women toiled to bring that touch of special caring to patients like him.


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