Written by: Kishan Kashyap, Shubham Agarwal, Vaishak P
If there is one thing that the Government has been exceptionally good at – it is its public relations and image management. On the 22nd of March in 2020, people gathered in their balconies and outside their houses across the country for the “Thaali Bajao” event where we were asked to bang utensils in support of frontline workers. In his address, the Hon’ble Prime Minister mentioned that this show of appreciation would “boost morale” and let them know that they are “valued and respected”. By asking people to partake in this “grand” gesture, he allowed everyone to feel like they were “doing something” for frontline workers, to draw on this collective feeling of “look how much we care and how much we’re doing!”.
Perhaps it is indulgent to bring this overused proverb into the mix, but empty barrels do indeed make the greatest noise; it is hard to view the event as anything but an obscure plot to distract from the fact that this public show of appreciation was not backed with any central provisions or targeted effort to ensure that our “corona warriors” are not merely drinking from empty cups. Of all our frontline workers, perhaps the ones with no cups at all are our Accredited Social Health Activists (ASHA Workers) that have been leading the aggressive fight against COVID-19 in the remotest of locations and have been front and centre in our contract tracing efforts.
Despite ASHA workers being the team at the centre of our national COVID-19 containment strategy, they have been excluded from larger conversations that discount their needs as a consequence of their “voluntary” status. They are “volunteering” their time and therefore are not considered a priority in health allocations. What is strange, is that ASHA workers (even before the pandemic) are the force that keeps our ailing primary healthcare system alive. Imagine that – the backbone of primary and natal healthcare of a country of 1.3 billion people is formed by a group of volunteers; it is their mobility and access to communities that enable our government to ensure last-mile healthcare delivery.
Image source: ANI
When reading about their voluntary work, one may be tempted to feel grateful that they are, of their volition, choosing to take the risk of exposure to help protect our communities. What this does, however, is that it allows the populace to feel acquitted of the need to delve deeper – by being appreciative, we placate ourselves with this excuse of them being “volunteers” to not have to contend with the terms of their appointment and the systems that continue to oppress them. The “Thaali Bajao” was just a clever smokescreen preventing us from examining the lacunae in the claims of support offered to them.
ASHA workers have, throughout this pandemic, not just been actively working on contact tracing, providing supplements to and arranging logistics for those that are most vulnerable – but have also been performing their “regular” tasks. Immunization programs continue. Women are still having babies and need ASHAs to assist them. While not the focus anymore, it is still very well a part of their work profile. ASHA workers are managing this by dedicating every hour of their day to this cause, often with no reprieve. As per government “orders”, ASHA workers are expected to survey entire communities and fastidiously log details of these inhabitants. These orders prescribe a limit of 25 households a day. When speaking with the general secretary of the ASHA workers union in Haryana, however, it was revealed that district-level pressure and the sheer volume of households has ASHA workers often surveying upwards of 100 households a day.
The cherry on this free labour cake, however, is that they are expected to do all of this without the safety of personal protective equipment (PPE). Despite repeated requests to department officers, ASHAs are still not granted the most basic of supplies (sanitisers, masks) when their core job is to interact and survey scores of people, some of whom are likely COVID-19 positive. Not only are they denied PPE, but they are also granted no form of health insurance. There is a cruel irony in the fact that these “health workers”, expected to risk their lives on the pretext of “serving the larger cause”, are allowed to become health hazards – not just to communities, but to themselves and their own families.
“We have been raising the demand for regularisation of ASHA workers for years now. COVID-19 has only added to our woes. Since March, most of us have been working for more than 10 hours a day, with no increase in honorarium. If anything, the list of unpaid tasks has grown”, said Sunita Rani, one of Haryana’s ASHA leaders we engaged with. “The pandemic has subjected us to added burden from both ends. On one hand, community surveillance and contact tracing demanded extra hours at work, while on the other hand, household chores increased because our husbands and kids were at home for most of the day”, added another ASHA leader.
Put in a situation where they were given a shovel and asked to build a dam, the woes of ASHA workers extend beyond the general disregard for their wellbeing. They were (and still are) expected to navigate this maze of information and work with people without any data or direction. They are required to download applications that provide them with survey resources, but with low tech literacy and the lack of smartphones, most had to resort to purchasing ones themselves, borrowing ones, or left to wade through the byzantine systems with no help and mounting expectations. In 2018, the Haryana government claimed that they would be issuing Android phones to the ASHA workers to bring them into the digital workforce for better penetration and connectivity – that claim is still yet to be realized.
Amid working with rigid and apathetic officers, they also face heavy discrimination, violence, and active boycotts by residents. Most ASHA workers come from socio-economically disadvantaged backgrounds and in multiple incidents across the country, upper-caste households refused to be surveyed by ASHA workers, objected to them posting quarantine stickers outside their doors, and staged violent attacks. This violence and stigma extend beyond just the individual ASHA workers to their families, with ongoing death and rape threats, and ostracization. They are, quite evidently, caught between a rock and a hard place.
At this point, there is another question that begs to be asked – does the designation of being “volunteers” magically open them up to being treated as departmental scapegoats? In Haryana, ASHA workers were asked by district collectors to man public distribution (PDS) stores, assist police screening, and generate other ad-hoc reports. Refusal to do this work invokes penalties and “explanation letters” followed by arbitrary incentive cuts. These “incentives” are what is offered for their voluntary service – amounts that are paid upon completion of tasks – tasks specific to their “healthcare worker” profile. This incentive has been fixed at Rs. 1000 (per month, unbelievably) by the central government. The Haryana state government allocation stated that they would pay an additional 50% bringing the amount to Rs. 1500, only to have that budget rolled back. The incentive is based on outcomes – however, with no standardization, the tasks considered for this “outcome-based payment” are changed at the whims of department officers.
The role of these female community health workers as the backbone of the healthcare system and their problems and demands aren’t unique to India but extends across the entire South Asia region. Known as Lady Health Workers in Pakistan and Female Community Health Volunteers in Nepal, they play an equally critical role in providing information and raising awareness and facilitating access to public health care. In fact, Pakistan fares better than the others by guaranteeing a minimum wage to these community health workers.
Earlier this month, on the occasion of Universal Health Coverage Day, these workers came together to stand in solidarity with each other and to develop a charter of combined demands, urging their respective governments and international health organizations to take heed. Organized by the Public Services International (PSI) in form of a virtual press conference, these health workers raised the following demands-
Recognition as Public Health Workers
The lack of formal recognition of public health workers leads to a loss of their legitimacy. As well-known public health advocate Anant Bhan pointed out: “ASHAs (and other community health workers) are structurally vulnerable to intimidation because they are perceived to have low status – they are female, at the base of the hierarchical health system, often not rich, not formally employed by the health establishment and are not salaried workers.”
Aimed at the Governments of India and Nepal, this entailed timely payment of adequate living wages that are not below the minimum wage of equivalent workers, overtime pay as per the country’s laws, social security entitlements, pension payments, leave entitlements, additional pandemic-related payments amongst other demands.
In India, it is important that we pay attention to the use of “volunteers”; a nomenclature is a powerful tool, and in this particular scenario, it allows the Government to shirk the responsibility of providing resources that would otherwise be made readily available to institutionalized health workers. By recognizing them as “volunteers”, the government becomes their greatest exploiter. Threatened with institutional action, lack of opportunities due to the ongoing lockdown, societal expectations and guilt-shaming, and often being the only earning members in the family (however paltry the sum), ASHAs do not have a choice but to continue a thankless job. To volunteer, a person must have options, the agency to choose. When there is only one option available and it is imposed by authority, it is coercion. This is a strategy that preys on the circumstances of the dispossessed and masquerades as a “frontline workers appreciation movement”. It is with the need for this recognition, for the dignity of work and being paid a fair compensation, that ASHA workers across the country have launched the movement to be instituted as permanent workers during this pandemic.
A collective voice in decision-making processes
Meaningful participation of civil society, as well as citizens with an emphasis on marginalized and vulnerable groups, leads to more inclusive, well thought out policies, especially when this participation is not reduced to tokenistic public relations gestures. This sentiment has been echoed by groups and thinkers across the world, including the United Nations Secretary-General António Guterres.
Health workers take cognizance of this and rightfully demand a seat at the table. They seek a democratic voice through their collective representation in the decision-making process, a space for their representatives in policymaking committees for COVID response and recovery plans, mandatory social dialogue process in resolving health intervention implementation and monitoring issues, consultations for practical recommendations in the designation of essential services in communities, among other demands.
Occupational Safety and Health Protection
It is the primary role of Governments to ensure the safety and wellbeing of these health workers, as they soldier on and face the greatest risk of contracting the illness during the COVID-19 pandemic. On March 26, the Finance Minister Nirmala Sitharaman announced a medical insurance cover of Rs 50 lakh per person for frontline health workers such as sanitation staff, paramedics and nurses, ASHA workers, and doctors. However, an ASHA worker, on the condition of anonymity, tells us a heart-wrenching story that points to the inefficacy of this tokenistic announcement. In Rohtak, Haryana, an ASHA worker got infected with the Coronavirus in the line of her work. Her husband who had respiratory problems got infected as well and unfortunately passed away. However, the cries of her family, as well as her other ASHA colleagues, fell on deaf ears and the health department refused to come to her aid. “Samaaj itna nirdayi kaise ho sakta hai?” (How can society be so inhumane)- she laments with a cracking voice.
Reminding the Government of their obligation, the community health workers demand adequate safety protocols as well as the provision of sufficient PPE kits. The protocols should be well thought out and not a result of hastily taken steps, examples of which include mandating ASHAs to check the temperature of people without equipping them with digital thermometers which possibly put them at greater risk. Another ASHA worker mentions that they weren’t given any training at the beginning of the lockdown and just thrown at the deep end. Hence, they seek training on guidelines and protocols for COVID-19 care, personal safety, infection risk management tailored for community health workers and accessible in local languages. They also ask that COVID-19 be declared as an occupational disease under the WHO guidelines and ILO Conventions and a right of compensation and rehabilitation be granted should they be infected in the course of discharging their duties.
Dignity at work
The lack of formal status and the resulting lack of legitimacy further translates to greater marginalization and harassment. During the early stages of the lockdown, this came to the fore when other departments of the government and not just the health department started bossing ASHAs around. In Kurukshetra, Haryana, the district collector ordered ASHAs to be stationed at grain mandis for eight hours every day. The police joined in and they were asked to be present at the police station to identify infected residents. And this is not a new occurrence. In Muzaffarpur, Bihar, more than 100 children died of Encephalitis in 2017 because ASHA workers supposed to keep tabs on children were asked to conduct election duty.
The government’s lack of empathy and concern has in the past stripped these workers of their basic dignity as well. They had to struggle for two years after the National Rural Health Mission (NRHM) decided to print ASHA on the condom packets distributed by them among people for the sake of family planning. An ASHA worker from Bhiwani, Haryana recalls incidents of eve-teasing and shouts of “Aye ASHA, Condom de” (Give me condoms, said in a derogatory fashion) as a result of this campaign.
With this in mind, they demand a work environment free of harassment and violence, a dedicated helpline for health workers to receive information and support relating to public health as well as problems faced, a strong grievance redressal mechanism to ensure timely resolution, a strong media campaign to explain to the community the role that CHWs play to help counter the stigma attached to the work they do, and adequate and free menstrual health services for female frontline health care providers.
Effective and Sincere Care
They further demand comprehensive healthcare and life insurance coverage, regular free testing, free treatment, care, and support for CHWs infected with COVID-19. They seek guaranteed compensation and life insurance in case of death or permanent injury of any workers, including from contracting Covid-19 in the course of work.
In a 16-state survey, from Kerala to Tripura, ASHA workers—who routinely clock over 12-hour days and are on call the rest of the time—reported feeling alienated and undervalued for the disproportionate burden they now bear in India’s battle against Covid-19. A 2017 study found over 60% of ASHA workers to be under a significant level of stress. The disproportionate burden they now shoulder in the battle against COVID-19 and the lack of support from the government and society has only compounded this stress.
An ASHA Union leader from Haryana tells us that most ASHAs are under depression which has gone unnoticed. This gets substantiated in a 16-state survey of ASHAs conducted by BehanBox where ASHAs cite feelings of being undervalued and alienated amidst long working hours to be the cause of this stress. Their unwavering commitment to their work also leads to domestic discord as well as their alienation in the community, as pointed out by gut-wrenching stories from Haryana.
In Bhiwani, an ASHA worker got called on to submit a report urgently while she was preparing breakfast for her family. Torn after repeated follow-up calls, she left the food preparation midway and went to discharge her duties. When she came back a few hours later, a fight ensued with her husband. Already under immense pressure, she took the drastic step of committing suicide. Since she hadn’t left a suicide note, the administration brushed aside the pressure of work as the reason behind her suicide, even as several of her colleagues pointed out to the same. In another incident, an ASHA worker was ostracized from her community after she reported a wedding in the village to the authorities. She was only discharging her duties, but the villagers saw it as a betrayal of their trust.
Health workers across South Asia demand mental and psychosocial support with regular mental health check-ups, support, and counselling sessions, to cope with the severe mental and physical exhaustion and anxiety faced due to overburdening work stress during this COVID-19 crisis. They seek arrangements for crèche and childcare within the communities in which we work as well as exemption from Covid-19 duties for pregnant, lactating, CHWs of a certain age or with existing health risks. Amidst other asks, they rightfully demand nutritious food/meals at the health posts or a food allowance to feed themselves.
Over the last eight years, they have raised their voices, staged protests, and gone on strikes, only to have been faced with empty promises and FIRs. Their protests are often met with threats of the Essential Services Management Act (ESMA) being invoked. In fact, in March 2018, the Maharashtra Government’s Women and Child Development department did the same, snatching the democratic right to protests from two lakh Anganwadi workers. Ironically, the state that fails to accept them as workers decide to pass such a regressive order. An ASHA union leader tells them that the two national parties, BJP and Congress, both have, at different occasions found their demands valid and promised to fulfil them. The catch- they do so, only when they are in opposition and do a U-turn on their promises as soon as they get elected.
Image Source: The Indian Express
When ASHAs demand that gynaecologists and paediatricians be staffed at community health centres, the authorities tell them that this is not for them to raise. (Only 2 out of 128 health centres in Haryana have gynaecologists, even as state government guidelines mandate their presence) When they raise the issue of regular pay and status as formal workers, they receive reactions ranging from apathy to ignorance. A leader from Hind Mahila Sabha based out of Uttar Pradesh (UP) tells us that the UP Chief Minister Office refuses to grant them appointments. Some sympathetic bureaucrats agree to meet but feign ignorance, knowing that the asks are legitimate, but they can do anything.
In Bihar, ASHA workers from multiple villages pooled money to be able to send one representative to Patna to participate in the month-long strike in front of the health department and the chief minister’s house. However, they all had to return after a month of dejection. When we asked an ASHA worker from Bihar whether she would participate in such protests again, she says that she is not interested. She says that nothing came out of it and I lost my income for a month. She further bemoans the lack of any form of attention from media, saying that “Kam se kam Akhbaar mein nikalta to lagta koi sun raha hai” (At least, if the newspapers had covered it, we would have felt heard).
We talked to a senior IAS officer who agreed that their demands were legitimate. However, he cited that the major implementation roadblocks include the pressure on the fiscal system to fund the formalization of workers and increased incentives as well as the need for formal recruitment processes to bring ASHAs under the ambit of formalization. She also argued that a fixed salary can lead to complacency, whereas an incentive-based system ensures accountability. However, she agreed that the steps taken so far have been grossly inadequate. It must be pointed out that India’s public expenditure on health is a mere 1.28 % of GDP which puts India at 170 out of 188 countries as per the Global Health Expenditure database 2016 of the WHO. There is clearly space for more expenditure to strengthen the primary care of the country and empower those who are the first line of defence.
The ill-treatment of female healthcare workers also brings to the fore the patriarchy embedded in our systems and furthers consolidation of the gendered division of work, undervaluation of female care work, and widening pay gap. The idea behind legislating employment of only women as ASHA workers initially emerged as a response to increasing female participation in the labour force. However, it is immensely clear that it was fundamentally important that women exclusively participate in these care-providing roles.
The ASHA workers’ scheme appears to build upon the prevalent patriarchal belief that it is a women’s inherent duty to provide unpaid care work. A brief look at the care duties enlisted in the scheme tells us how most of them are considered to be an extension of women’s unpaid care work provided at home. Therefore, making the program women-only, allows the government to classify a lot of tasks as non-monetary, and benefit off women’s undervalued work. However, the truth remains that the availability of such crucial unpaid work offers a significant subsidy to the formal economy, given that a healthy workforce is critical to the efficient functioning of any economy.
On-going strikes by the ASHAs due to the non-fulfilment of promises and denial of basic terms of service by the government has hampered the delivery of essential healthcare services to rural households, including child vaccinations, pregnancy care, and tuberculosis control. Losing the frontline ASHA workers will also seriously endanger India’s COVID-19 containment efforts.
The pandemic has underscored the wisdom in appreciating frontline healthcare workers. ASHA workers are a precious resource who relay important information to disconnected places. India has so far been fortunate to have not had to deal with large-scale community transmission, but the emergence of a new highly-transmissible strain coupled with the absence of our frontline warriors threatens to change that. It is our responsibility as citizens, willing to come out and bang utensils, to not let hollow appreciation swallow their cause and to back them when they need us most – not just because of how much we need them.
Kishan, Shubham, and Vaishak are second-year students at the Indian Institute of Management, Ahmedabad and can be reached out at email@example.com.