By Mitali Nikore & Vidhi Narang*

Almost 40% of India’s healthcare workers and 83.4% of nurses and midwives are women (WHO, 2016). Over the last year, almost 2.5 million Anganwadi workers (AWWs), auxiliary nurse-midwives (ANMs) and accredited social-health activists (ASHAs) have walked, swum, and trudged across the length and breadth of the country, risking infection and working over-time. They have gone door-to-door to distribute Government relief, spreading awareness on COVID-19-safe behaviors, monitoring COVID-19 patients, and assisting pregnant women.

In light of the COVID-19 crisis, the World Health Organisation (WHO)  has dedicated the year 2021 as the ‘International Year of Health and Care workers’. WHO also acknowledged the importance of community engagement by India’s female social health activists (ASHAs) in India as an effective strategy to prevent, track and treat COVID-19 infections. (IPPPR, 2021). Yet, despite receiving praises and applause, these frontline female health workers continue to be neglected when it comes to legal entitlements and protection.

First, ASHAs and AWWs are not entitled to a fixed monthly wage from the Central or State Government. Despite being responsible for community level healthcare in rural areas, immunisation, nutritional care and maternal/childcare services, they are considered part-time volunteers.

AWWs and helpers are paid monthly honorariums under the Centrally sponsored Integrated Child Development Services (ICDS) scheme. In 2018, the central government increased the monthly honorariums of AWWs from INR 3,000 to INR 4,500 per month after a gap of seven years (GOI, 2019).

ASHA workers earning largely consist of performance-based incentives, tied to the number of beneficiaries. These are set by State governments, from their share of allocations under the Central government’s National Health Mission (NHM) (PIB, 2020). Following the lead of  West Bengal and Rajasthan, states like Haryana, Karnataka, and Odisha have also decided to pay fixed monthly amount to ASHAs, in the range of INR 2,000 – INR 6,000 per month, with Andhra Pradesh announcing a hike to INR 10,000 per month in 2019. Maharashtra increased honorariums by INR 1500 to INR 7500, including INR 500 for COVID duties in June 2021. Yet, a vast number of States continue with variable pay regimes. Delays in payments of ASHAs have been routine across the country (GOI, 2018).

Second, these female frontline health workers were largely unable to benefit from government support during COVID-19. In March 2020, the Central Government provided INR 50 lakhs in health insurance for healthcare workers – including ASHAs and AWWs. In April 2020, the Central Government introduced a COVID-19 incentive of INR 1,000 for ASHAs. In June 2020, GOI announced that withholding medical practitioners’ salaries is a punishable offence under the Disaster Management Act.

Yet, despite these statutory entitlements, several ASHAs, AWWs and ANMs reported non-payment and medical equipment and PPE shortages. An Oxfam survey of ASHAs noted that 75% of respondents received masks, 62%, gloves and only 23% received body suits, mostly only once. A dipstick survey conducted by Nikore Associates also found that receipts of COVID-19 incentives were marred by delays, and the amount was too low to cover sanitizer and PPE costs in several States. Several ASHA workers and AWWs reported working longer hours with little means of virtual communication (TIME 2020). They were distributing Government relief rations despite challenges like public ostracization, often without access to personal transport (National Geographic, 2020).

In January 2021, the Health Ministry announced India’s first priority group to be vaccinated against the virus. The group consisted of frontline workers, including ASHAs and AWWs. While this recognition was an acknowledgement of their services, it came with additional responsibilities. ASHAs and AWWs were deployed for assisting in execution of the vaccine rollout across country and also during the vaccine dry run conducted earlier in the month. Further, they were also sent out to create awareness about vaccination process among other frontline workers, adding to their already heavy workload (GOI, 2021).

Third, Central Government’s financial support for frontline health workers saw a decrease under the Union Budget 2021-22. Even as the Health Ministry’s budget increased by 9.6%, from INR 65,011 crores in 2020-21 to INR 71,269 crores in 2021-22 (Department of Health and Family Welfare, 2021-22), allocations for the ICDS decreased 29.5%, to INR 20,105 crores in 2021-22 from INR 28,557 crores in 2020-21 (Ministry of Women and Child Development, 2021-22).

In order to recognize that AWWs, ANMs and ASHAs are a central pillar of public health service delivery, particularly for women and children, there is an urgent need to invest in strengthening these services through four quick steps:

1. Fixed monthly income. In line with the recommendations of the Parliamentary Standing Committee on Labour (2020), ASHAs and AWWs should be recognised as employees, not volunteers, making them eligible for fixed monthly income and social security benefits. Their base salaries also need to be increased by State-level committees.
2. Clear and manageable responsibilities. ASHA and AWWs currently manage multiple responsibilities (child nutrition, women’s health, data collection, etc.). Under the New Education Policy 2020, AWWs are also expected to contribute to early learning. Prior to the pandemic, ASHAs were working between 7-8 hours per day. With the addition of new, COVID-related responsbilities, this increased by a further 2-3 hours per day, resulting in both physical and mental fatigue (Singaraju and Mandela, 2020). A new organisational framework, with detailed job roles and payment bands commensurate with skills and experience and duty hours is required.
3. Skill-training and certification. Within this new organisational framework, work experience and skilling certifications should be introduced to institute seniority levels and specialisations. Specialised trainings, e.g. nutrition, maternal health or early learning, should be offered, linked with higher pay.
4. Technological support. Public private partnerships and corporate social responsibility initiatives should sponsor hi-tech solutions and mobile applications for data collection, monitoring and evaluation, building on successes like the Tata Trusts ‘Making It Happen’ program, which lowered operating costs and improved women’s nutritional status between 2017-2019 by deploying advanced monitoring software solutions at Anganwadi centres in Rajasthan (TATA Trusts, 2020). Frontline women health workers need to be equipped with digital devices and training.

Mitali is Founder, and Vidhi is Research Advisor at Nikore Associates, a youth-led economics research and policy think tank.