'ASHAs are not a panacea for all problems': Dr Abhay and Dr Rani Bang | Pulse Maharashtra

追加: 2026-05-30

[00:00:00]Inspired by the ideals of Mahatma Gandhi, a doctor couple in one of the remotest areas of Maharashtra affected by Maoism has been working tirelessly for rural and tribal health for over four decades now. Several national and international recognitions have been bestowed out upon Dr. Rani Pank and Dr. Abhai Pang. In all these years I'm in Gioli in the sprawling campus of search of society for education action and research in community health founded by the bang couple sitting right across them.

[00:00:45]Hello and welcome to pulse Maharashtra with me the nayadesh pandep pandit. I'm the Maharashtra chief of bureau of the Hindu and your host for the show and today I have with me the pioneers of community-led health initiatives Septua generans Dr. Rani and Dr. Raang thank you so much for your bless time for the Hindus I'm going to begin by asking you it's been two decades since the ashas started working in India it was primarily thanks to your initiative in community le public health service how do you look at asha services now and how do you review this entire period critically what needs to be done now >> asha is a name for community health work female community health worker in village idea is quite old even Mahatma Gandhi and Raata they started something like trained community health worker around there then people like Dr. A roles in Zamar they also trained community health worker. What we did in Guli that's we identified a woman in each village and trained her to manage very serious condition which used to kill children in India.

[00:02:07]These were pneumonia in children and newborn care and not only we were able to drastically reduce child mortality in this part of children. So through field trials controlled field trials they could show that there is serious scientific evidence which was published by the lancet and that gave its international credibility.

[00:02:31]Asha program was conceived by then UCA government around 2006 >> 2005 >> one reason was that the access to health care was very poor in the '90s government failed for a world bank pressure or IMF pressure that people should pay for their services and receive private care even government services started charging charging fees so access to healthare remarkably reduced.

[00:03:03]UP government really made a qualitative change and national rural health mission and Asha these two ideas were floated.

[00:03:13]Asha's ideas as I said there were several barefoot doctor in China. So there were several inspirations but probably Guli program showed them clearcut evidence that it can be done and it effectively reduces child modernity.

[00:03:28]So I think it was a very major step to accept by the government that the nonprofessional like the semiade village woman that she can be entrusted with the responsibilities of healthcare.

[00:03:44]When we used to do lobbying with the government that there is a need in village but you don't have any worker in the five lakh villages of India. So there is a need for a community health worker. The resistance was both from bureaucrats and techocrats.

[00:04:00]What would the semi woman would use? You always need doctors. They used to compare with the international standard.

[00:04:06]But Indian villages did not need international standard. They need something which was immediately accessible 24 hours. So finally when government was convinced and they introduced Asha program initial some years really went into what would she be doing. Guli model and the Nitthan model in Chhattisgarh. These two models helped government of India to design Arsha program.

[00:04:33]We trained the trainers national trainers who trained district trainers who trained about 10 lakh ashas. So currently there are 1 million ashas in India and last year they provided homebased newborn care in their villages to 15 million rural mids. So this period saw the most remarkable drop in child mortality which had never been seen so rapid reduction.

[00:05:01]So ashas have proven their effectiveness not only in reducing child mortality using homebased newborn care but there several other programs. Now actually health department I'm using it in a in a complimentary sense that health department is now addicted to asha.

[00:05:18]>> Yes they >> cannot become the backbone >> they cannot do anything in village without asha whether it is covid control or malaria control or TV control or hypertension diabetes detection everything Asha is the frontline person.

[00:05:33]So it's a remarkable tribute to the capacity of a rural woman that if you give her training opportunity and then medicine supervision and financial regulation he can really do miracle.

[00:05:48]That's why the logo that we created for homebased newborn care is that in a dark hut a woman is alone but on a raise empowered hands she can take care of the health of her child as well as of the village. So Ashas have really done remarkable contribution to India's healthcare and today we if health department has some presence though inadequate but some presence in six lakh villages thanks to Ashas and ANF >> but Dr. Raniba we have seen that for the last few years the Ashers have consistently been hitting the streets.

[00:06:25]They have been raising several demands that they say have not been met with what we think should be the way in which ASHA should be valued and their contributions should be recognized because it's not just the health services that Asha are you know offering to people but beyond health as well there are several other jobs that have been put on their backs in Maharatra for example you see for large the workers have also been the frontline people to have been a part of the enrollment. How do you see that they consistently feel that they are not valued?

[00:07:07]I feel that ashas are overburd and everybody talks about asha and we have forgotten now ICBS worth malaysia workers they should be given proper importance that is one thing should not be considered as banish for all the problems there has to be limited responsibility which she can do properly So like family planning program in line.

[00:07:45]So family planning program was supposed to be punished for all the problems.

[00:07:50]Same thing is happening with a I think that can reduce the quality of that.

[00:08:00]>> Quantity everything is everything is based on quantity. M >> this work that work with that word that work I think when importance is given to only quantity quality definitely suffer.

[00:08:15]So government has to decide what are our really mainh priorities and work on that and I think here uh the people who are working in the field they can play major role and they should play major role. So ashas need to be given more role but defined what currently is being done that you identify the illness and bring to the door of PSC but there is no doctor at that PSC there is no community health officer often not often upsent and so instead of making her merely a recruitment agent of patients for healthare system she should be empowered to manage cases that's one that will give her more credibility instead of the she saying to everything to you have some illness now go to the PSC for the illness.

[00:09:13]>> Secondly that uh her training and supervision needs to be strengthened.

[00:09:19]>> Third is she should regularly get her financial incentive. Her payment is largely linked with amount of work that output that she produces. Now once you have made this kind of financial arrangement that you should be honest to it you should pay her adequately for whatever work she has done system is not very efficient in that. And finally this is true that ashas are doing not only several work but in our area we find that people often insist that Asha should become sarach. our community health work that I initially trained many of them villages want her to become serpent of the village. So actually there is so much needed at the village level health work that you need two or three community health workers in each with village.

[00:10:11]So along with Asha in addition to her there is a need for one more male and one more female community health worker for 1,000 population health care needs especially in the era of non-communicable disease.

[00:10:27]>> Every village now has got 200 hypertensives >> and about 40 diabetics >> and then old people who need much more care. What a single asha can do. So we need to expand the quantum of community health workers at the village level. You need at least two or three community health worker. I have even designed a name I coined a name for male community health worker. Ashoke Ashoke one who reduces pain and suffering. So Asha and Ashoke that is the minimum that each Indian village needs and deserves.

[00:11:02]When you say that what is the quantum you're talking about as compared to the you know millions of Asha workers that we have right now how many Ashok should India have >> India has got nearly six lakh villages and if you include tribal small villages pad also that might go as much as 1 million. So the same number of male workers I would say same number of additional worker whether male or female would depend on the job description probably female workers would be more stable in the villages males are always looking for job around so female would be more stable but one limitation of arsha is that they may not be so much reaching out to the male clients for example vict use of neurode but they may not be so effective. So a pair of male and female worker probably will create access to all the population but additional worker could be male or could be female.

[00:12:06]>> But doctors we are also talking at a time when we see that the public extended care on health is questionable.

[00:12:13]Both of you started your work with the aim of arug highly inspired by Mahatma Gandhi's ideas. this is what you wanted you know to happen in India which is why you chose Chiru which is one of the most underserved areas which is you know which had so many problems infant mortality ratio but at a times when you know we are seeing that more and more focus of health services is towards privatization how do you see India achieving the goal of arrogaraj we mean that as much as possible people should be able to take care of their own own health by determining how do they how do they live my health depends on my diet my exercise my mental peace my use of substances tobacco alcohol if I don't change these then only thing I am going to do is to get a cancer or get a stroke or heart attack and then end up at the door of medical care and so arugas means I am empowered order to take care of my health individually, family wise or community wise and most of the care for illnesses should be possible within the community. Who which villager wants to go to some city and wait outside the hospital. So they want they need everything in their own village. We should be able to provide that. So power in the hands of people in individual and family to prevent illness to live in such a way that illnesses won't occur.

[00:13:54]Now tobacco and alcohol have become so common in India. Fast foods have become very common. Excess use of sugar and salt have become very common and these produce all non-communicable disase.

[00:14:07]Once you develop non-communicable disease like heart attack, stroke, diabetes, hypertention, cancer, then it's lifelong disease. It needs their level of first. It's not first. It makes you wor depend on somebody else.

[00:14:23]And so empowering people to live healthy lifestyle to manage their own health in their own hands and especially modern technology makes it imminently feasible.

[00:14:36]Now with the self monitoring devices you can monitor your pulse rate your BP your sugar your ECG can be taken and te connection so that if your ECG is wrong immediately you will get warning signal the modern apps and ty connectivity have made it eminently possible that people should be able to manage their own health and more we do it more we will reduce their dependence on the medical care system still for 10 20% illnesses advanced medical care system will be required their government cannot turn its responses into government has to provide for that countries in the Europe on an average spend about 10% of their GDP on healthcare and their GDP is very high >> yes >> so 10 for example US spend 17% GDP on healthcare which comes to about about 10 lak rupees per capita per year.

[00:15:38]We spend something like 6,000 rupees per capita per year and government spends state and central together around 1% of GDP on healthcare.

[00:15:50]So huge amount of resources have to flow in instead of that crowds to get into medical colleges actually public health services which health promotion prevention and primary health care that's where we need our emphasis and the current government allocation to healthcare must increase three to four times that is necessary >> but Dr. I personally feel like this is very important whatever has said and we are doing the same thing but nowadays villages are growing. There is no concept now that village is a unit.

[00:16:27]There is a rapid urbanization >> and people are very much tend to go to district place or medical college. I think there also they also should be standard >> because the posity of doctors there that is also an important aspect which we ignore.

[00:17:02]>> Most of the doctors nowadays they are tend to settle in big cities. There is no concept of private practice.

[00:17:14]Now one person cannot run the clinic. So so many doctors have to come together.

[00:17:20]That's what how corporate sector is created.

[00:17:24]So in urban areas we should be able to motivate the doctors there not only just uh medical care but also the preventive care that is very important. Nowadays what is happening they are supposed to treat they treat all the chronic diseases but the primary health care in urban areas that is probably the real test. So there also we should be able to emphasize and also >> our next question to you that you know how do you see the fact that public health system has its own problems how does it compound women's problems is it more difficult for women there >> yes definitely I mean this I just give you one example previously we used to have this dai concept who used to delivered in the villages. Nowadays D concept is totally gone and that is because of the health problem of the government.

[00:18:36]>> Institutional delivery that every woman should go to hospital and she should deliver there. The women who are getting the services at home. We don't need uh very elaborate services at home or in the community. But now what is happening the doctors at the community level there at sub center the nurse is there in rural hospital another doctor is there district hospital another doctor is there and because of this concept that not a single death should occur maternal death or in uh infertility and so nobody wants to take risk so there is like a hierarchy that is there in medical community. So if patient comes to PSC even for delivery she's sent to sub center >> district hospital >> district hospital and there is tremendous load in this >> which of course uh affects the quality of the care in district hospital.

[00:19:51]So and secondly what has happened is because of this institutional deliveries the number of cesarian sections has rapidly gone and I talked to many doctors they say that who is going to awaken the whole night >> and look after that patient most of the deliveries they take this in the night >> so we don't do s inction we didn't with money and at that time we can finish our job everywhere. I have seen these uh doctors women doctors saying that like in other sector government sector they have a job from 10 to 5 or 11 to 5. So same day all the doctors should have respect for you.

[00:20:44]>> That's what that's what doctors >> understand that going to affect that is already affected.

[00:20:51]>> So on one hand there is a large scale of commercialization of medical >> on the other hand you know there see you know the problem with the public health system as well and you know how do you find a sustainable solution to this?

[00:21:07]Look you were earlier asking about the human resource in healthare system in most of the developed countries 2% of population is involved in providing health care.

[00:21:22]Now imagine if we apply same proportion their salaries in the US will be different than in India but 2% of population is required to provide healthcare.

[00:21:33]So an average village with 1,000 population should have 20 persons assume that half of them would be in urban areas in hospitals etc. So India should have altogether nearly 30 million people involved in healthare from Asha and Ashoke to A&Ms to lab technicians etc to >> tertiary care surgeons but India should have 30 million people involved in healthare and India's health budget should be at least three times more and then the picture can change >> but then do you see that you know the villages is the tribal areas the hamlets particularly the marginalized of the most marginalized are left in alerts because of his gaping threat to the public health system in the large scale commercialization and how it is going to address that >> but that's what arug idea can provide for arug means that apart from government system we should be there and probably there is going to be a private system also you can't completely put it aside But then 70 80% of health preservation and healthcare role is shifted to the village level and then the attribable villager doesn't have to go to cities for everything.

[00:22:57]Most of the health prevention like the vaccination we provide in the village iron folic acid tablets we provide in the village. Similarly for most of the healthcare issues can be provided in the system and 20% 30% maybe higher centers are necessary tribal villages will become more accessible if we select individuals from the village itself and train her or him to provide healthare.

[00:23:25]If you if you select doctors from Mumbai and Delhi and compulsorily ask them to go and live in travel they are not going to. We haven't had enough 70 years experience failed experience that you can't operate that model. So better idea would be select a potential man or woman young man or woman from the village and turn her and him into barefoot doctor.

[00:23:50]So in in tribal villages if they can do their farming, if they can do their forestry, why not healthare? Healthare can be simplified and made accessible to tribal villages also. So six lakh Indian villages need a health care small but healthcare autonomous system in each village.

[00:24:11]>> That is Aruk that is arrog. On one hand this is very important but nowadays these uh villagers they have they also another feeling they want to go to big hospitals they want sonography in every case nowadays they're talking about CT scan in every case MRI in every case they come with different doctor's prescription at the same time they bring sonographies of different doctors >> so that There is also another thing going on and with people in village they have also different expectations that what was their case.

[00:24:54]>> So we have to take it in consideration >> but that can be made available with running. Look now on our mobile medical unit we have put mobile X-ray and we have put mobile lab. So in every trial villages our mobile medical unit takes X-ray laboratory and medical care. Now not so far CT scan and sonography but with emerging technologies more and more simplification would happen. The machines are becoming smaller and smaller and with tele connectivity and with tele consultation the expert might sit in cities but he or she can offer intellectual services to even tribal village. So I I I I see a very much possibility that with AI where the program if X-ray is taken in the village by a technicians AI would give diagnosis or a teleconultation doctor sitting somewhere might give diagnosis. So the advanced medical care facilities can be made available right in a tribal village or in any of the six lakh villages of India. Government needs to have that vision. vision of Aragaraj not merely medical insurance through corporate hospitals >> which which means you're saying that adequate medical infrastructure funded by the government at rural areas which can then be combined with AI and tele medicine services am I right >> in addition to empowerment of the human beings in the village so AI teleconultation would be additional the real thrust would be give knowledge and lifestyle healthy lifestyle to the people of villages and give community health workers who would assist them at the village level.

[00:26:37]>> I think I we should also be very clear now because of the expectations of the people and they want good services. We always talk about tele medicine that is very very important but who is there on the other end? Who is the specialist who is giving the care advice? I have seen some doctors.

[00:27:04]They say we don't have that is a we usually say that they should be telling medicine and all that but who is there at that and is there if if at all there is the advice is accepted how to bring the medicines the investigations not every investigation is available at rural level.

[00:27:36]>> So we have to think in total perspective not just community not just for hospital but there should be some middle uh solution and we have to proceed in respect >> Dr. I want to ask you something with respect to specifically women's work.

[00:27:56]Now your work has been pioneering with respect to women's reproductive health.

[00:28:00]We've seen also how there was a global shift of focus from birth control to women's reproductive health influenced because of your work but even today challenges remain. What do you think are the biggest challenges in India when it comes to reproductive health of women and how challenging do you think is you know this very you know over the counter sale of medicines especially when it comes to women's health reproductive one is cancer like you see merging that's a big problem both breast cancer and thal cancer nowadays MTP law was there in India since 1972 and number of illegal abortions or criminal abortions but nearly six times more than the legal abortions. That time we said that there are there are no services in rural area. So we strive to provide services in rural area but for the what is happening is the technology on I am not of course to technology technology is important but now after bill and emergency contraceptive pill that is uh that is creating bad thing because most of the women married women and most of the unmarried girls and now this premarital al sex.

[00:29:30]Previously also it was there in our study we saw that 48% of girls have premarital sex but the any abortion which is done uh without the doctor's not without the doctor's prescription. So that is called in at a certified center that is called illegal abortion. But previous other type of illegal abortion. Nowadays we are having other type of illegal abortion. So women take the medicines on their own. They don't know what is the uh uh regime how to take the medicine and they don't know what are the side effects of the medicine. And this whole thing needs lot of health education not only in villages but in urban areas because most of the educated women they don't know anything they think that it's very easy do anything the technology which is there to help >> but what are the harmful effects on the reproductive health when such overthe-counter prescription overthec counter medicines are taken without prescriptions >> one thing is natural problems, irregular menstrual problems and heavy menstrual problem. At the same time, some medicines if they take hormones, it may ultimately lead to infertility because the ovelation is suppressed.

[00:31:01]Yeah, it affects adolescent and sexual identical because of this many girls and boys they indulge in irresponsible sex and infection is there but at the same time prem marital pregnancy nowadays in that is also there and in rural area most of the less they resort to this criminal abortion. So irregular menstrual cycle and women in India are very much concerned about menstrual cycle menstrual flow and if there is a heavy manes they think it is normal. If there are there is less uh menstrual strokes they also they think that that is the most dangerous thing.

[00:31:58]So they are very much worried when they take all these medicines they are very much worried about the infertility problem or in general their total health because they think that if the meas flow is less that is that is going to kill that organ because that vessel blood collects inside the it's very important it impinges on the But I fear die.

[00:32:30]>> That's what they believe.

[00:32:31]>> That's what >> also retained products if they use medicine for abortion.

[00:32:37]>> Abortion because of this self induced abortion. Uh many times women and girls they come with incomplete abortion and there are products attained inside the uterus which is very very serious because that may cause infection in long run that may cause infertility and secondly cancer danger is also there. So all these things are taken into consideration sexual education of boys and girls. I think that is one of the missing lings and it should be added. We were talking about when we were talking about reproductive health, we said that reproductive health should include all these aspects safe and effective uh family planning uh services because previously there was all the emphasis only on the targets. Now also the government had changed the policy on paper that it won't be targetd driven uh family planning. Family planning would be for the better health of women and children but it is not there.

[00:33:56]>> Even both of you while speaking now have talked about the importance of sex education particularly among adults about among young adults.

[00:34:06]We see that the conversations around sex education have been diffusing in India.

[00:34:12]What is the significance of sex education? At what age should it be imparted and how should it be?

[00:34:19]>> Right? You should start from the age 12 because nowadays women are because of the physical growth.

[00:34:29]The minority is happening at the early age >> and they get they are exposed to sexual relationship at such an early age. Then either they take contraceptives or either or they go go for illegal abortion. When we say illegal abortion, it's not the abortion done by the wax or other doctors, medical doctors, even MDL doctor without any license right if he does abortion that is considered as illegal abortion. So adolescent sexual health education should include all this things. You know you have been giving sex education here at search for tribal gate specifically.

[00:35:18]How has your experience been? Has it changed any behaviors when it comes to sexual behavior among tribals when you see that long-term sex education is imparted for adulthives.

[00:35:30]Look society is changing because of so many forces and as all of us know first the TV then mobile phone YouTube and pornography everything is impinging and reaching to tribal villages so it's difficult to say what is changing their behaviors their knowledge has definitely increased the sexual education for adolescent that surge does gives them a long and remarkable information and sometimes even attitude education youth will change it >> but it is difficult to attribute it to a single factor because all those things are happening simultaneous and I think now media is shaping their attitude towards sexual health rather than anybody else more than healthare system is the media what they see in films >> you know I'm I'm now going to ask you to know something really difficult that is to judge your own people. So you know 40 years ago you started search from a warehouse in one of the most underserved districts of India till which is where you're sitting right now. It was also one of the worst blood for India's day.

[00:36:49]How do you look back at the journey? How has searched evolved and what are the challenges ahead?

[00:36:54]>> So by baby you mean search?

[00:36:56]>> Yes.

[00:36:57]Not your two babies who have taken over from you. Now >> we have grandchild also. Actually when you say baby I first think about my grandson.

[00:37:11]I think when we were studying in the US we used to think and when you are abroad your own country becomes even more dear to you. So we used to dream after returning what will we do? We were committed to improve health of rural India. That's what that's why we went to the US to learn public health research.

[00:37:36]So whatever dreams we had developed I think we were fortunate that we we could do much more.

[00:37:45]It was in a way a hard journey but a beautiful journey very rewarding.

[00:37:52]Initially we made some planters and fortunately we didn't crumble but we learned from those mistakes and listening to people was the most remarkable thing that we added to our methods. So listening to people and com simplifying science taking to them but whatever we did we validated through scientific methods. So though we were able to provide service locally the research impact happened globally.

[00:38:25]So it was great to work in Guli but to influence the health policies in Geneva, New York, Washington and Delhi that gave whatever work search did locally it gave enormous impact to it. We have called that method as research with the people.

[00:38:43]So arug and research with the people. These two methods one dream and another method they have made whatever service or research we did here plus look providing service I have worked in urban area also when we were studying in medical colleges it's very impersonal care not only patients don't feel satisfaction but even doctors don't feel satisfaction you have a crowd of 100 patient you Kasai Khana you treat patients there is no person relationship. Now here in Guli in tribal villages when we see patients we know you come from Uda or you come from Pundai and in your village such and such old man is there and so you can establish personal relationship with the patients and you can see that patient subsequently and someday or other you meet that patient in the grave. So providing health care to tribal people is very rewarding. They are so grateful and maybe you you do contribute a little significantly to their lives. So they are very grateful. So instead of crowding and going in urban area where there are lot of crowds of specialist doctors, you also open your shop. So what is value addition?

[00:40:06]It's so so much more rewarding to come to tribal area provide healthare where there is nothing >> while talking to women in rural area only I I found that they have taught us more than what we have given what are the things which were never I never learned in medical talking to women they What? How the people perceive different types of medicine? What are their practices?

[00:40:44]If they take medicine, why? If they don't take medicine, why? So, we always take it for granted that we are the doctors. We know everything.

[00:40:56]>> Can you give us a few examples? When you say you learned when women interacted with you, what did they tell you that you learned from this? Now I'm going to in this sessions with uh traditional birth attendants I used to tell them that I will teach you something and you teach me next year something it should not be one way process.