South Asian women community health workers demand labor rights and occupational safety

On the International Day for Universal Health Coverage, Public Services International brought together Community Health Workers from India, Pakistan and Nepal for the launch of the campaign “Community Health Work is Work”

December 14, 2020 by Pavan Kulkarni
Illustration: Nirupama Viswanath for PSI

On December 11, the International Day for Universal Health Coverage, Community Health Workers (CHWs) in South Asia, who play a crucial and frontline role in public healthcare systems, were brought together by Public Services International (PSI) in a press conference.

Demanding recognition of CHWs as public health workers, and measures to enforce occupational safety, a campaign called “Community Health Work is Work” was launched.

CHWs from India, Pakistan and Nepal recounted their struggles in the press conference which was also attended by Anand Grover, India’s former UN Special Rapporteur on the Right to Health, and representatives from the International Labor Organization (ILO).  

Working without PPEs, these workers, almost all of whom are women, have been on the frontlines of the fight against the COVID-19 pandemic. However, they complained that their governments provided no support when they got infected on duty.

In India, CHWs are known as Accredited Social Health Activists or ASHAs. A member of Nagpur Municipal Corporations Employees Union (NMCEU), Yamuna Tekam, an ASHA worker in Nagpur – the third largest city in the State of Maharashtra which is one of the worst affected by the pandemic – said, “During the lockdown, when everyone was told to stay home, we were under enormous pressure from our family members to not go outside. But we were told to either work or tender our resignations. They threatened to recruit others to replace us.”

“We defied our families and were prepared for service. We were deployed to Satranjipura, the biggest hotspot of COVID-19 in Nagpur, without PPEs.” 

Surveys to identify those with symptoms and awareness campaigns conducted by the ASHA workers were critical in organizing the efforts to check the pandemic.

Perceived as carriers of the virus, they were harassed on duty by paranoid residents in the localities, who tried to prevent them from conducting the surveys they were tasked with. Such instances, including physical assaults, have been reported from multiple cities across India.

“Despite all this, we successfully conducted the surveys,” Yamuna said. In the course of their duty, several of her colleagues contracted the virus. In one case, her colleague’s two children and husband also got infected due to the exposure. Under quarantine, they were left with no income and had to rely on help from good Samaritans, she said. Eventually, the man’s health deteriorated and he succumbed.

“There was absolutely no assistance from the government.. We were not even paid the 200 rupees (about USD 2.7) per day that we were promised. We were paid only 30 rupees (40 cents), adding up to about Rs. 1,000 (USD 13.6) per month,” she said. 

Stressing that even under such adverse circumstances the ASHA workers have continued their duty, she insisted that the government should recognize them as health workers, just like doctors or nurses.

India’s Ministry of Health and Family Welfare recognizes ASHA workers as “an interface between the community and the public health system” and the “the first port of call for any health related demands of deprived sections of the population, especially women and children, who find it difficult to access health services.”

However, they continue to be treated as activists to whom small stipends are paid, rather than as workers with labor rights and minimum wage.

CHWs in Pakistan had led the way in this struggle, winning recognition as workers with a right to minimum wage after a major campaign in 2008. Halima Zulqarnain, the central president of the All Sindh Lady Health Workers and Employees Union (ASLHWEU), recounted the struggle to win this recognition.

“We held sustained protests and demonstrations, where we were attacked by the police with batons, tear-gas and water cannons. We were arrested and charged with terrorism. In jail, many Lady Health Workers who were pregnant had miscarriages,” she said.

While they are now entitled to a minimum wage, getting it in practice is often a struggle. During the pandemic, their experience of being vulnerable and abandoned by the government was similar to that of their counterparts in India.  

Lady Health Workers, as they are known in Pakistan, are tasked with going from house to house to monitor the health of mothers and children, promote awareness about family planning to control population growth, and to administer polio vaccinations.

“This is the work Lady Health Workers have to do on a daily basis,” she said. Despite the high risk of exposure, “we have not been provided with masks or PPEs or sanitizers. Neither have we been provided with nutritious food and medicines to improve our immune system.”

“More than 22 of my colleagues in my own team have tested positive for Covid-19,” Halima added. “We are constantly working in danger, with little help from the government.” Even the families of those workers who died after contracting the virus on duty did not receive any compensation, she complained.

Kate Lappin, PSI’s regional secretary for the Asia & Pacific region, commented that “the situation in Pakistan is really illustrative for the rest of the world.. They (CHWs) are still delivering the Polio vaccine, which most of the world has eradicated. And the difficulty (in delivering).. the vaccine, particularly to the remote areas, is actually life-threatening for the workers. And we won’t be able to eradicate the current virus unless these workers are properly supported and respected, and given the support that public health workers require.”

Community Health Volunteers, as the CWUs are called in Nepal, have a 24/7 job, said Gita Thingg, the vice-president of the Nepal Health Volunteers Association (NEVA). “Sometimes we are called at midnight if there is any health issue or accident,” she said.

In Nepal, the weather conditions make this particularly dangerous. “We have a number of cases when the Female Community Health Volunteers traveling from one village to another at night in thick fog were swept away by the river during floods. Many people ask ‘you are not even being paid. What do you get out of this?’ And the answer is, just basic snacks and travel allowance,” Gita said.

But these adversities have not led her to think of quitting this work. Unable to pursue her dream of becoming a doctor due to her economic circumstances, she chose to join these women whose service to the community inspired her. She insists that people dedicated to this service should be treated as workers, and not volunteers.

“I’ve never met a Community Health Worker who doesn’t passionately believe in her work,” Anand Grover said. Stressing on the importance of these workers, he added, “I feel the CHWs are the most important of the health care workers.. not the doctors and surgeons. Because the healthcare system.. is based on the primary healthcare. If you do not have primary healthcare, you cannot provide healthcare at all.” The primary healthcare system thus simply cannot function without the CHWs.