An Accredited Social Health Activist (ASHA) in Jalangi block in West Bengal’s Murshidabad district, Sabina Yasmin visited at least 20 households every day in remote villages to deliver health and nutrition services at the door-step. She recorded births, deaths, pregnancies, nutrition levels; physically examined people for common ailments like flu, skin and water-borne diseases; provided medicines and nutritional supplements; and paid daily visits to homes of all pregnant women in her area tracking their progress and ensuring institutional delivery.?
But that was before the pandemic. Her monthly payment at the time, including fixed and variable components and comprised of funds provided by the Central and state government, ranged Rs 6000-6500. Most of the beneficiaries of her work comprised families of migrant workers, who began returning to their native villages in droves from other districts and states after the imposition of the nationwide lockdown on March 24, 2020.?
“When migrant workers began returning to the villages, we had to visit an additional seven households of such workers every day, and keep a record of their movements,” recalled Yasmin. “Plus, in every household we visited, we had to watch out for symptoms of COVID-19 infection. We had to physically examine suspects, record their temperature, counsel and link them up with testing and treatment facilities, monitor those in home isolation and trace people who came in close contact with infected patients,” she said.
Yasmin received no additional pay for the extra workload as a frontline worker in the pandemic. Worse, she was neither provided with any medical insurance, nor protective gear like mask and sanitizer despite the “touch-oriented” nature of her work and the high risk of infection. “The government gave us two cloth masks in 2019. It’s already over two years. But I guess they want us to use them for a few more years,” she laughed.?
“Many of us got infected, including me,” she continued. “I underwent pacemaker implantation when I was young and fell severely ill after getting infected, and was hospitalized for 16 days. The district medical officer ensured I got a bed in a designated COVID hospital because I am known widely as a leader and activist, but most of my colleagues were not so fortunate, and many died,” said Yasmin, also Secretary of the Paschim Banga ASHA Swasthakarmi Union.
Yasmin’s concerns resonated with those raised by other community level frontline women workers – including accredited social health activists under the National Health Mission, anganwadi workers and their supervisors under the Integrated Child Development Services programme, and nurses working in government in private hospitals – and activists in West Bengal and Maharashtra.?
Officially, there are over 10 lakh ASHAs and 25 lakh anganwadi workers and supervisors spread across the country who are serving as frontline workers through the pandemic. They are engaged in health and nutrition delivery, growth monitoring, and disease surveillance and detection, but Shubha Shamim, vice-president of All India Federation of Anganwadi Workers and Helpers and Maharashtra State General Secretary of Anganwadi Karmachari Sanghatana, said their primary task was that of prevention – including through early detection of cases that can reduce chances of serious health complications among the infected. “Doctors and other medical staff, whose primary task is to cure the patient, come in much later,” said Shamim.?
Whereas Trisheela Kamble, General Secretary of the Municipal Nurses and Paramedical Union in Mumbai, drew attention to the undervalued role of nurses, mostly women, in treatment and care. “Nurses spend much longer hours in wards compared with doctors. They are the ones who actually administer treatment and care, necessitating physical contact with even COVID positive patients,” said Kamble.
Yet, nurses, ASHAs and ICDS workers feature nowhere near doctors, who are predominantly male, when it comes to job security, entitlements, pay commensurate to the criticality of work and attendant risks, and even social recognition.?
For instance, while July 1 is marked as National Doctors Day in India, no such day is earmarked nationally to recognize the services of nurses and community health workers. In fact, when doctors were being widely venerated as COVID warriors around Doctor’s Day this year by governments, business entities and the media, nurses and ASHA workers were on strike in Delhi, Maharashtra and other states demanding better pay, medical insurance and other entitlements, underscoring deep disparities.??
Shamim, Kamble, Yasmin and other frontline women workers and activists flagged three key areas of disparity between doctors on the one hand, and nurses, ICDS workers and ASHAs on the other, when it came to recognizing their role as frontline workers during the pandemic. A cursory examination of these disparities showed how they built on existing social hierarchies around caste, class and gender – such that doctors who were largely men from dominant castes came off at the top; community healthcare workers, mostly women from lower caste groups, featured at the bottom; and nurses, mostly women from across caste lines, fared somewhere in the middle.?
The first disparity flagged by frontline women workers and activists was around recognition in the legal sense as workers. They contended that since registration was a prerequisite for doctors and nurses to practice, it accorded them legal recognition as workers protected under labour laws. Whereas ASHAs, ICDS workers and trainee nurses required no registration, were mostly engaged on contract for paltry payment, not covered they under minimum wages and labour laws.?
“We sent many deputations to the Central and state government even during the pandemic asking them to recognize ASHAs and ICDS workers as workers in the legal sense, so minimum wages and social security rights are enforceable, but all pleas have fallen on deaf ears,” said Ratna Dutta, General Secretary of Paschimbanga Rajya ICDS Karmi Samiti.?
“Many of these women workers have spent years demanding recognition as government employees performing crucial full-time jobs as front-line health workers…However, the view that these women, who implement India’s health and nutrition goals at the grassroots level, are merely honorary volunteers instead of actual workers remain strongly entrenched,” noted a recent research study.
Subir Niyogi, an unorganised sector activist based in West Bengal’s Paschim Bardhhaman district drew attention to the plight of trainee nurses. “Most small hospitals and nursing homes that treated COVID patients here hired ‘trainee nurses’, mostly passouts from small-time nursing schools, to cope with increased demand for beds and patient care during the pandemic. Their employment was rarely shown on paper, which allowed owners to pay them meagre salaries or stipends and deny them social security benefits,” said Niyogi.
The second disparity flagged by frontline women workers and activists was around wages, entitlements and social security. They said that while most doctors had reasonable job security even in the private sector, received handsome monthly payments and consultation fees, and accessed medical insurance, PF and other social security schemes with ease, ASHAs, ICDS personnel, and trainee nurses were paid paltry salaries, honorariums or stipends, and not covered under medical insurance and other social security schemes.?
For instance, in West Bengal, doctors working full time with government and private hospitals said starting salaries in their hospitals ranged Rs 40,000 and upwards, whereas nurses in these facilities said starting salaries ranged Rs 20,000 and upwards. They said that although most doctors and nurses had access to social security schemes, the condition of trainee nurses was worse – their salaries ranged Rs 6000-7500, they hired and fired at will, and not given any medical insurance despite the high risk of infection.
ICDS workers and ASHAs were similarly deprived of fair wages and social security entitlements. While ASHA workers reported receiving an average of Rs. 4000-7000 per month depending on their location, scope of work and targets met, ICDS supervisors and workers were paid Rs 8350 and Rs 6250 per month, respectively. None of these workers reported receiving any medical insurance in lieu of high infection risks due to additional responsibilities as frontline workers. Most did not receive any help with finding hospital beds or treatment when they were infected.
The third disparity flagged by frontline women workers and activists was around allowances for additional work and compensation for death or disease. While the Union government and various state governments have announced compensation schemes for frontline workers including doctors, nurses, and community health workers, media reports show that these benefits are not reaching those located at the lower end of existing hierarchies, who need it the most.?
For instance, community health workers and activists in West Bengal said at least two ASHAs and 9 ICDS workers had died in the state since the first wave after being infected, but none of them had received compensation under the Union government’s ‘Pradhan Mantri Garib Kalyan Package Insurance Scheme’ for Health Workers fighting COVID-19, which entitles the family of deceased ASHA workers to a compensation of Rs 50 lakh.
The large number of strikes and agitations enforced by nurses, ASHAs and ICDS workers in Delhi, Maharashtra and other states through various waves of the pandemic also provide a clear indication of unrest among women frontline workers, whereas governments seem reluctant to turn promises into orders.?
Armaity Irani, Secretary, Centre of Trade Unions, Maharashtra State Committee, explained how this was panning out in Maharashtra. “ASHA workers in the state went on a strike on June 15 (2021) protesting against lack of protection, meagre pay and other issues. We called off the 9-day long strike after the state government promised to provide a COVID allowance of Rs 500 per month, in addition to a one-time allowance of Rs 1000 to ASHA workers and Rs 1200 to block facilitators, and a further increase of Rs 500 for both from July 1, 2022. But nearly a month has passed and the government has not issued any GR to the same effect,” said Armaity Irani, Secretary, Centre of Indian Trade Unions, Maharashtra State Committee.
“The National Health Mission issued an order after March 2020 saying ASHAs would be paid an additional Rs 1000 for pandemic-related duties, but the scheme was stopped abruptly after six months, and many workers did not receive payment for all six months either,” scoffed Pijush Mishra, Acting President of Paschim Banga ASHA Swasthakarmi Union.?
Brinelle D’Souza, Chairperson of the Centre for Health and Mental Health, Tata Institute of Social Sciences, Mumbai, and Co-convenor of public health advocacy group Jan Swasthya Abhiyan said disparities in entitlements and recognition of frontline workers amidst the pandemic was only natural given that the medical profession is extremely hierarchical and power structures well defined.
“Women’s labour has always been severely undermined and undervalued in the medical field and nurses have traditionally been seen as soft-skilled care-givers. Their clinical skills and roles are not acknowledged in the same way as that of doctors – they are viewed as 'helpers' to doctors. Poor women's labour, on the other hand, is undervalued and under compensated even more – that is why ASHAs and ICDS workers who constitute a critical component of the country’s health system also occupy the lowest rungs in the same system as well as in society. They are appraised on their performance like employees, but they are not recognised as workers, which contributes to their exploitation,” she said.
D’Souza and others felt these hierarchies affected women health workers at the grassroots who were committed to their work and the community the most. Whereas Yasmin’s experiences as an ASHA worker during the pandemic in West Bengal’s Murshidabad district showed how this was true. “I had to walk back over 18 km from the block hospital to my home on three occasions when I accompanied pregnant women to the hospital delivery. This was because rules stipulate that ambulances are only for ferrying pregnant women to the hospital, not for taking families or ASHA workers back home,” she said.
Yet, Yasmin was more concerned about how hurdles and challenges posed by the pandemic might affect community health. “According to the latest data from National Family Health Survey (Round 5, 2019-2020), institutional deliveries accounted for over 91 percent childbirths in West Bengal. But this figure may witness a significant drop as many women and families are reluctant to go to the hospital for delivery amidst the pandemic when public transport is either suspended or severely curtailed,” she rued.
The writer is a Kolkata based freelance contributor.