Key workers are essential for societies to function, but India has been repeatedly pointed out by international reports as a county that does not care for its key workers as in the case of ASHAs, or even does not recognize as the key workers as in the case of waste pickers, which increases their plights.
The latest reference has been made by the World Employment and Social Outlook (WESO) 2023 of the International Labour Organisation (ILO) on several counts, including the plight of ASHA workers who were awarded with the title of Global Health Leaders by World Health Organisation (WHO) in 2022 but India not even recognizes them as employees.
In many developing countries, the working conditions of key health workers are especially poor, with low pay, job insecurity and high workplace safety and health risks, the WESO 2023 said. To substantiate this assertions it gave the example of India’s ASHA workers. In India, the situation of Accredited Social Health Activists (ASHAs) is of particular concern, the WESO report said.
ASHAs are female community health workers appointed under the National Health Mission, a programme that was introduced in 2005.Over a million women across the country work as ASHAs, bridging the gap between the community and the health system. They are responsible for a range of public healthcare services addressing maternal and child health, and communicable and non-communicable diseases.
The important role of ASHAs is documented by their positive impact on communities: in the localities where they work, immunization rates are higher and mortality rates have declined. During theCOVID-19 pandemic, ASHA workers raised awareness about the virus and safety protocols, tracked positive cases and assisted with vaccinations in addition to their usual responsibilities of providing maternal care, immunization for children and community healthcare. In 2022, the WHO Director-General awarded ASHAs the title of Global Health Leaders.
It should be noted that ASHAs are not only appointed but also trained by the National Rural Health Mission in India. Workers are selected among women in the community, aged 25–45, with completed secondary studies. They carry out various tasks, including providing first-contact healthcare and information on diseases and infections, and bringing patients to hospitals if necessary.
Even though ASHAs are appointed by the government they are not recognized as employees and are only paid “incentives” that are linked to achieving certain targets. Following protests by these workers, several states introduced a fixed wage component and the central government also increased the incentives that it contributes.
The average pay of ASHAs, the WESO 2023 said, amounts to 10,000 Indian rupees a month (approximately US$120), and ASHAs report that they sometimes pay the transportation costs of the patients they bring to hospitals from their own income, so even the little money they make sometimes goes to job-related costs.
Furthermore, many ASHA workers report that they receive their payments with delays. ASHAs face other occupational challenges besides low and delayed payments. One of them is a heavy work-load. For example, more than a third of community workers in rural areas are responsible for more than 2,000 people. Reaching this many people in rural areas is also logistically challenging, especially as many report a lack of buses and rickshaws in the areas in which they work.
ASHAs also face violence and harassment, with many reporting verbal and physical assaults. The lack of cooperation from the communities they work in and the scarcity of resources, such as waiting areas or photocopy machines, are some of the other problems ASHA workers highlight.
Additionally, these workers do not have formal communication channels and access to supervisors to raise their concerns and seek solutions.
It has been argued that many of these problems are linked to the ambiguous status of ASHA workers, who are seen as voluntary workers or bahus (daughters-in-law) rather than employees.
During the COVID-19 crisis, the workload of ASHAs increased considerably. ASHAs played a decisive role, taking care of contact tracing, testing and isolation, conducting door-to-door surveys, distributing medicines and sometimes bringing food to patients in isolation, answering distress calls and organizing hospital transfers. They were also in charge of keeping records of vaccination progress and motivating people to get vaccinated.
In parallel with these demanding new tasks, ASHAs continued to undertake their usual antenatal and postnatal care duties, including monitoring infant health. While most ASHAs were provided with masks and sanitizers, these were often insufficient in terms of quantity and quality, with many reporting that they had to purchase PPE at their own expense.
Despite hurdles, and even in very difficult times, ASHAs operated in the country as a team if they encountered any difficulty and filled in for each other during periods of leave. They worked even when they denied access to public transportation as well as suffered physical assault during COVID-19 pandemic. One ASHA worker recounted the stigma that she and her colleagues endured thus: “During COVID-19 times, even neighbours would also say all kinds of things. That this woman goes all over, she will bring COVID-19. Some of the ASHAs who were renting their home had a lot of problems as the owners pressured them to vacate. … I know ASHAs who had to vacate and didn’t have anywhere to go. They stayed in the hospital till they could find a place.”
However, there were also consolations for ASHA workers that came not from the government or other people carrying biases against us but by the suffering families as an ASHA worker from Hyderabad has thus been quoted, “The families where people got COVID-19 positive really appreciated us and blessed us. When we would go to give them medicines or help them go to the hospital, they would really thank us. Some even said we were like angels who came to help at a time even extended family and friends were not coming forward. When they said these things, we felt very happy.” (IPA Service)