Community health work is work

Bobby Ramakant *

This year the Universal Health Coverage (UHC) day is different in a way that never before the UHC message was so loud and clear. From first case of coronavirus eleven months ago to nearly 70 million cases worldwide, the pandemic has made us realize how essential is health security for each one of us - and - unless we ensure development justice for each one of us, no one is protected.

Primary healthcare is the fundamental building block of health systems and community health workers who provide primary healthcare services are the true champions. More importantly, community healthcare work, is also an essential work - failing which, our entire health system is threatened.

Community health workers across the south Asia region have united in solidarity and launched a campaign to assert their rights as workers. Kate Lappin, Regional Secretary for Asia and Pacific, Public Services International (PSI) said that community health workers across the South Asia region play a critical role in providing primary healthcare, raising awareness, and facilitating access to public healthcare to hundreds of millions of rural people. In South Asia, community health workers are almost entirely women who are expected to do this vital work without being recognised as public health workers and without the payment of adequate wages.

precarious work is a threat to public health

Kate added that community health workers currently face the risk of contracting COVID-19 through their work but are perversely denied health and life insurance as well as pensions. Governments have recognised community health workers as 'warriors against COVID-19' yet have routinely failed to provide adequate personal protective equipment (PPE) kits, training, wages or support.

Their repeated requests for provision of safety kits, masks and sanitisers during the COVID-19 door-to-door visits and surveys has been denied by the authorities. With increased risks of exposure to the virus, the pandemic has illustrated that precarious work is a threat to public health.

World Health Organization (WHO) has long recognized the role of community health workers underlining that they "play a crucial role in broadening access and coverage of health services in remote areas and can undertake actions that lead to improved health outcomes."

Rosa Pavanelli, General Secretary, PSI stressed that it is important to formalize the relationship of community health workers with public authorities to enhance their quality of working conditions. This pandemic has shown that how tragic is the scarcity of health professionals globally. No country has been able to keep on treating patients at the level necessary.

International organizations including the WHO are relying on greater task sharing by community health workers to strengthen primary healthcare. It is the women who shoulder lion's share of this essential work. It is necessary to establish policies for ensuring labour and professional standards as well as adequate training and support. It is also vital for governments to regulate the working conditions of all healthcare workers. Rosa added that COVID-19 pandemic has brought home the reality of primary health care as an essential filter to reduce the pressure on hospitals or emergency care.

Unions representing community health workers have documented a range of threats and violations experienced during the pandemic. Community health workers are facing heightened risks of infection and enduring long working hours, psychological distress, fatigue, occupational burnout, discrimination and physical and psychological harassment. Many community health workers have reported not being paid during the pandemic.

In India, there are three groups of community health workers: Accredited Social Health Activists (ASHA) who are all women, Auxiliary Nurse Midwife (ANM), and Anganwadi. Yamuna Tekam, an ASHA worker since four years, represents Nagpur Municipal Corporation Employees Union (NMCEU). Yamuna said that during the pandemic, family wanted her to be home but authorities pressured her to go to the field with a mask.

She was not given PPE and seldom got a glove. Abuses were hurled upon her or survey form was torn or water thrown on her colleagues. Three ASHA workers tested positive for COVID-19 in her centre. She was given Rs 30 per day (Rs 1000 for a month) which was far less than what was due.

Halima Zulqarnain, Central President, All Sindh Lady Health Workers and Employees Union (ASLHWEU), Pakistan, said that community health workers are referred to as Lady Health Workers in Pakistan, and were appointed since 1994 at Rs 900 a month for family planning programme in rural areas. Despite doing vital work, they were not treated with due dignity like other healthcare professionals were.

When they started the movement to get their due, they faced resistance - water was thrown on them, some of them were jailed, some suffered miscarriages in the struggle. One health worker also got a divorce when she went out on the streets demanding justice and rights.

Lady health workers were working during the lockdown but were not given sanitizer, PPE or compensation for this precarious job. Not surprisingly, more than 20 of them tested positive for COVID-19. Halima demanded safer working conditions for all lady health workers, dignity and respect like other healthcare professionals, and fairer wages, insurance and pension.

In Nepal, community health workers are called Female Community Health Volunteers. Gita Thingg, Vice President, Nepal Health Volunteers Association said that they have played a vital role in reducing maternal and infant mortality rates nationwide. In Nepal, the title of 'female community health volunteers' suggests 'voluntary' work but it is 24x7 work, says Gita.

Snacks and basic travel allowance is not a justified compensation for this important service they provide. She demands that government must recognize the critical role they play in health system with dignity. Since 2010 she has been unionising in Nepal to claim the rights and benefits long overdue to female community health volunteers. "We are working, doing labour and we should accordingly get paid, and recognized with dignity and respect, and our rights protected" said Gita.

Jyotsana Shakya, Treasurer, Health Volunteer Organisation of Nepal said that her two family generations have worked as female community health volunteers. Even though the Nepal government ordered involvement of female community health volunteers in committees to respond to COVID-19, this was not well implemented at local level. Despite promise of Rs 1000 allowance by federal government, the local authorities have not paid them.

Mask, sanitizer or PPE was not given to them. When they got tested for COVID-19, almost all of them tested positive and were not allowed to go back home. They were forced to stay in community homes and often the blame was on them. Her union has submitted demands to the government now which includes oximeter. Mayor of her region has assured her of support. They rightly want to be recognized as workers, not mere volunteers. She also demands health insurance for all.

Anand Grover, former UN Special Rapporteur on the Right to Health and senior lawyer in Supreme and High Courts of India, said that every person must have a right to health. Every person is entiled to good healthcare facilities and services which are available, accessible, acceptable, and of good quality - and government has an obligation to ensure this for all.

Community health workers are not volunteers but workers - and - most important workers - because healthcare system is based on primary healthcare. If we do not have primary healthcare we cannot provide health for all. Unless we treat community health workers as 'workers' and not 'volunteers' how will they assert their right to be paid as per the pay-scale of the government?

Anand Grover said that community health workers have done their work with utmost sincerity, professionalism, and most importantly, passion - without the remuneration they are entitled to. He shared that Vidya vs state of Maharashtra legal case shows how an anganwadi worker was told by the High Court that she is entitled to be treated as worker according to industrial laws and thus can go to the labour courts for justice.

Public Services International and unions representing community health workers across South Asia launched a list of joint-demands that include:
- Recognition as public health workers
- Collective voice in decision-making processes
- Occupational safety and health protection
- Dignity at work
- Care for us
- people-centred healthcare system.