The COVID-19 pandemic has brought along a significant increase in workload for health workers of different profiles. The lack of personal protective equipment (PPE) for physicians and nurses working with COVID-19 patients has been reported on by mainstream media in virtually all regions of the world. On the other hand, the position of others, like community health workers, has often been glanced over by the media, while their contributions to delivering health care during the pandemic have been exploited by governments in many countries.
Community health workers continue to represent an essential point of access to health care for many in low and middle income countries. According to a recent publication by Public Services International (PSI), they account for 43% of the total health workforce in Pakistan, and as much as 46% of the total health workforce in India. Such numbers show that their role in health care delivery is crucial, especially among the poor and those in communities with limited access to hospitals and health centers. However, their relevance has not translated to the formalization of their position inside the healthcare system, or even access to the equipment necessary for their work, including PPE.
Problems exacerbated by the COVID-19 pandemic
As a result of these issues, community health workers in several countries have resorted to demonstrations and strikes even during the pandemic, highlighting that they, like all other health workers, deserve support and recognition for what they do. Among them, community health workers in India, known as the Accredited Social Health Activists (ASHA), organized strikes across the country at the end of May, raising concerns about late or partial payments for the work they have done over the past year and the lack of access to adequate PPE kits — but first and foremost in order to secure formalization. In fact, although work arrangements for community health workers differ among different countries, and sometimes even within countries, the fact that their labor remains informal is a widely reported concern.
Similarly, community health workers in Limpopo, South Africa, held a protest in the first half of June, demanding that they be made permanent employees. Some of the participants warned that the local government still doesn’t perceive them as frontline workers, and use this as a pretext for paying them less than other health workers and rationing their PPE in a way that doesn’t allow adequate protection. The situation described in Limpopo is similar to other parts of South Africa, where in eight of the nine provinces, community health workers have virtually no access to rights like pension or a living wage. They are also often disregarded by both state and NGO employers when it comes to compensation under the Compensation for Injuries and Diseases Act, which should apply to all workers, whether permanently employed or on any length of contract employment.
According to Melanie Alperstein from the People’s Health Movement (PHM) South Africa, COVID-19 has amplified the effects of the informal employment of community health workers in the country. “But through self-organizing forums and unions, community health workers have begun strikes and protests, fighting for their rights,” she says. In addition to community health workers in Limpopo, Alperstein mentions actions by the Western South African Care Workers Forum (SACWF), including a march to the Health district office in Khayelitsha where they delivered a memorandum. Their demands included permanent absorption, bonus, back pay, and better working conditions, including the provision of PPE. Close to 1,000 community health workers from Cape Metro and surrounding districts attended the march.
Parallely, the Eastern SACWF coordinated community health workers in the Eastern Cape Province, and hosted a picket at the Provincial Health Department offices in Bisho. When no one from the department came to receive their memorandum, the protesters decided to organize a night vigil picketi. “Unfortunately, they were chased away by police who used rubber bullets and stun grenades resulting in some of them getting seriously injured,” explains Alperstien.
More examples of how community health workers have been disregarded during the pandemic have been documented in a brief compiled by PHM, illustrating a common thread of issues faced by community health workers from Malawi to the Philippines. We know that the contribution of community health workers to the response in somewhat comparable situations, e.g. the Ebola epidemic, has been invaluable. Yet, in all the documented cases, it is striking to see how much they have been disregarded during the recent pandemic. It is also worrying to notice that their work is still being used by governments as a strategy for reducing healthcare costs.
Weak healthcare systems exploit informal workers
In fact, the position in which community health workers find themselves today has a lot to do with the direction in which health systems have been moving for the past decades. Instead of securing enough funds for strengthening health systems, including training and employing enough staff, governments have focused on keeping costs to a minimum. This has meant that full-time permanent positions were replaced by less secure positions, and more and more tasks were shifted on volunteers, informal and semi-formal workers like the ASHAs and community health workers in South Africa.
The current situation is of course intolerable for the workers themselves: in addition to working long hours and doing jobs that are physically and psychologically exhausting for less than minimum wage, community health workers are still shouldering most of the unpaid reproductive labor at home, as highlighted in the PSI report quoted before.
On the other hand, health care systems themselves have been weakened by such an approach, as they can count on fewer workers and resources to fulfill their basic function. And although this has been known from before, the COVID-19 pandemic has put the implications into practice. Weak systems have proven themselves to be incapable of responding to the new stress. Instead, a lot of the burden fell once again on community health workers. The situation in which they find themselves today illustrates the importance of having strong public services to respond to ordinary needs and extraordinary events.
It is exactly because of this that one of PSI’s main demands for this Public Services Day, marked on June 23, was for governments to invest in public services during pandemic recovery. In the case of health, more investment has to mean decent working conditions for community health workers, starting from a formalized role inside the health system. According to Alperstein, improving the position of community health workers starts from transparent and appropriate recruitment and employment policies. “What we need is employment that ensures decent work and pay with full benefits, standardized education, but also supportive workplaces and involvement in and with broader community structures,” she notes.