Community health workers in South Asia forge joint struggle for rights and recognition

Frontline health workers have issued a joint document calling on governments and international agencies to recognize and uphold their essential rights

September 09, 2023 by Tanupriya Singh
ASHA workers at a protest in Delhi in 2017. Photo: Newsclick

Approximately 20,000 community health workers in the Indian state of Haryana have been on strike for the past three weeks. Known as Accredited Social Health Activists (ASHAs), they are part of a workforce of over one million women across India who are at the frontlines of public health care in rural and urban areas.

Despite performing nearly 60 critical tasks— related to preventive, reproductive, maternal and child, and broadly, community care— ASHAs are not recognized by the government as public sector workers. Instead, they are classified as “volunteers” — a precarious category that does not afford these women basic labor rights and protections including a minimum wage, sick leave, or pensions.

The ongoing strike in Haryana is part of a lengthy struggle waged by ASHA workers for recognition and fair compensation. Since the start of the COVID-19 pandemic, they have mobilized and participated in five country-wide labor actions and several state and local level protests and strikes.

ASHA workers in India are not alone. Other countries in South Asia have seen similar struggles by community health workers on issues ranging from their status as government employees, wages and social protection to problems related to sexual harassment and safety.

Community health workers in India, Pakistan, and Nepal have now joined together to release a Charter of Demands calling upon governments as well as international agencies to recognize and uphold their rights. Beginning with the declaration “Community health work is work!,” the document has been supported by the Global Union Federation and Public Services International (PSI).

“CHWs play an essential role in health education, monitoring, and vaccination programs. Working in the community, they are the primary messengers of government policies and campaigns…They have been the backbone for improvements in maternal and infant mortality rates across nations…They identify cases of diseases like tuberculosis,diabetes and hypertension in the community,” Kate Lappin, Regional Secretary for Asia Pacific, PSI, said in a press statement. “We hope that the governments consider the Charter of Demands launched today and improve working conditions of the CHWs.”

Workers, not “volunteers”

Among the primary demands being raised in the Charter is for the recognition of CHWs as public health workers entitled to public sector wages, protections, and benefits, as well as decent work standards as defined by the International Labor Organization (ILO). This includes remuneration that is at least equal to the prevailing minimum wage, overtime pay and pay-scales commensurate to experience.

Gita Thing, the president of the Nepal Health Volunteers Association (NEVA) which is among the unions that have produced the Charter, has been a community health worker or (Female Community Health Volunteer-FCHV) in Kathmandu for nearly 30 years.

While the set ratio for a FCHV is 1 per a population of 1,500 people, community health workers are currently individually serving about 3,000 people, Thing told Peoples Dispatch.

FCHVs in Nepal perform 90 separate tasks in their local community. These varied duties include identifying people afflicted with tuberculosis and giving them medication, collecting data on pregnant women, infants, and children below the age of 5, conducting education and awareness programs regarding nutrition, diseases and sanitation, vaccination campaigns (including taking people to vaccination centers), providing family planning advice, as well as contraceptive care.

Beyond these health-related tasks, CHWs also play an important social role within communities as mediators in household and other disputes. They are also tasked with identifying cases of child labor in the area, which they then have to report to the municipal authorities.

Instead of a set wage, FCHVs in Nepal are given an annual travel allowance of 12,000 Nepali Rupees (USD 90.3). Beyond that, for the duration of each government program or campaign that they are tasked with, they are paid a daily “allowance” of 400 Nepali Rupees (USD 3). While the allowance at the time when Thing first joined the FCHV program was about 50 Nepali Rupees (USD 0.38), the current level barely amounts to an increment of 1%, she said.

“The 400 rupees that we are paid right now we have achieved through the struggle of our union. We are now demanding that the allowance be raised to 1,000 nepali rupees (USD 7.5).” Thing added.

NEVA is also trying to change its name to replace “volunteers” with “workers,” in its struggle for recognition. As part of this effort, FCHVs have started registering as workers at labor desks that have been set up at the local level, a process which is being assisted by PSI. NEVA is also lobbying for the provision of social security for workers.

Given that CHWs are predominantly, if not exclusively, women, it is also important to note that this work is done on top of existing unpaid work by women in their own households.

“We are unable to sustain our families, to be able to afford the school fees for our children. We advise families to provide good nutrition for their children, yet we are unable to do the same for our own,” Archana Mishra, an ASHA worker from the Indian state of Uttar Pradesh and a member of the Hind Mahila Sabha, a union of women in the unorganized sector, told Peoples Dispatch.

ASHA workers in Uttar Pradesh are supposed to receive a monthly honorarium of Rs. 2,000 (USD 24.1) from the Central Government and Rs. 1,500 (USD 18) from the state government. However, the disbursement of this already meager amount is plagued by delays of up to six months, Mishra said.

“We are overburdened with work. At any given time, there are two to three national health campaigns or programs that are being implemented simultaneously– a lot of which is field-based work. When we registered as ASHAs, we were told that we would be paid incentives based on each completed task. However, what ends up happening is that if we fail to complete any one task, our entire pay is withheld.”

According to the set standard in India, each ASHA worker is responsible for a population of 2,500 people or 500 households. In Kanpur at present, there are 450 ASHA workers overseeing a population of 250,000 people, Mishra said, adding that the requirement on the ground was for at least 2,000 workers.

“What is this if not economic exploitation…We should be recognized as public sector workers, our employment should be regularized so we can at least get a minimum wage. We should be respected, we should have a health policy, an increment, opportunities for promotion, and pensions.”

While significant issues related to wages and benefits ultimately hinge on the recognition of CHWs as workers, as in the case of India and Nepal, problems have persisted even after such official recognition has been granted– as is the case of CHWs or Lady Health Workers (LHWs) in Pakistan.

“We are advocating for comprehensive healthcare coverage, regular disease testing, and mental health support. The Charter insists on decent working conditions, manageable work hours, and legal protections such as paid sick leave and mandated maternity leave,” said Iram Fatima, the chairperson of the Punjab Ladies Health Workers Union in Pakistan.

The backbone of the public health system

Given the critical role of CHWs in the public health system, the Charter also demands the inclusion of workers and their representatives in national policy-making, especially when it comes to designing and implementing protocols around public services such as COVID-19 recovery plan committees.

“Micro-plans for campaigns and programs are being drafted in air conditioned rooms without thinking about how an ASHA worker would actually be able to implement them in the field,” Mishra said.

“The government says that ASHA workers are the backbone of the health system. If that is the case, shouldn’t they strengthen the backbone instead of weakening it?”

CHWs have also called upon the government to put in place adequate occupational health and safety provisions, including the provision of Personal Protection Equipment (PPEs) and other equipment including safety tools and torchlights, and compensation in case of illness or injury.

ASHA workers were at the frontlines of the Indian government’s COVID-19 pandemic response, with their contribution also recognized by the World Health Organization (WHO). Despite being duties that put ASHAs in direct contact with people who potentially or had actually tested positive for COVID-19, they were not given sufficient protective equipment.

CHWs have also highlighted the need to create a work environment free from violence and harassment, and one that has provisions for grievance redressal and other forms of support.

“Our well-being matters, and we deserve the right to care,” Iram Fatima had stressed.

In this regard, the Charter calls upon governments to ensure that CHW’s are given comprehensive healthcare and life insurance coverage, compensation in case of injury or death, including during work-related travel, regular free testing and treatment of communicable diseases, paid sick leave and maternity leave. As well as the right to an eight-hour workday and the right to individually or collectively halt work in the event of unsafe working conditions or fear of exposure.

Governments must also provide access to mental and psychosocial support in the form of regular mental health check-ups and counseling, nutritious food either at the designated health posts or in the form of a food allowance, and housing for CHWs who may not have access to adequate housing in the community.

Ultimately, the Charter raises the call for a “healthcare system that prioritizes health over wealth” and grounded in the principle “that everyone can–and must– receive care”.

“A caring economy will require redistribution. While we have been contributing our labor and dedication for decades, billionaires and corporations are contributing little to nothing to support the public good,” the text adds, calling on governments to address flawed tax systems that “exacerbate inequalities and undermine our collective welfare.”