The coronavirus pandemic has invaded nearly every sphere of human activity in mere months. And while we are still battling the virus in tier 1 and 2 cities, it is only a matter of time before it starts sweeping our rural hinterlands as well. This calls for effective action at the community level, at the frontlines of which are our community health workers (CHWs). Recent news has brought to our notice that as these CHWs have been deployed in relation to the pandemic, they have faced resistance at least in some places. Some people misbehaved with them, snatched their phones and bags away, abused them, etc.
The government introduced this cadre of healthcare professionals to provide culturally acceptable primary healthcare. However, in certain underserved, rural and remote areas, they are the only medium through which healthcare is currently being delivered. Amid all the chatter on the COVID-19 epidemic in India, the plight and challenges of our CHWs merit examination as well.
When we talk about the work profile of these workers, the boundaries are indistinct since, with the addition of every new programme, whether central or state, the amount of work they are expected to do constantly increases. This often leads to ambiguity of roles and overburdening to the extent that the workers have become de facto paramedics. And even this role is frequently not accompanied by sufficient training. Additional responsibilities far exceed their capabilities. The increased workload, with no concurrent increase in remuneration or additional incentives, leads to loss of enthusiasm. All of this plus limited opportunities for vertical growth and job stagnation predisposes CHWs to dissatisfaction, leading to increased attrition.
Even though they can provide valuable on-field knowledge and experience and are important stakeholders in programmes, they are hardly involved in programme planning and design. Along with lack of autonomy, this generates a lack of ownership, giving rise to depersonalisation. Unfilled posts where they exist further stress existing staff with responsibilities, and into this cauldron is added paperwork and duplication of documentation. Though there is scope for digitisation, there is often a learning curve for grassroots workers with limited formal education. Lack of basic facilities and amenities, basic infrastructure, supplies, and equipment, and poor transportation further add to their woes.
There is also role attrition, in which the credit for the success of the programmes is often given exclusively to the planners. At this point, it is important to note that such workers are largely women and hence have dual responsibilities in their personal and professional lives. Family support is essential to their work. But despite their selfless and tireless efforts, CHWs are often only mentioned when they are to be blamed for something, especially since they are the first point of health-system contact in villages.
It was never going to be very long before the coronavirus pandemic brought the issues of these frontline health workers to the fore. In Karnataka, there was recently a day-and-night protest by ASHA1 workers for fixed monthly honoraria. ASHAs also agitated in Haryana for deposition of deducted remuneration, infrastructure like chairs and cupboards at the workplace, filling of vacant posts, and traveling allowances. In Telangana, the government reportedly attempted to create panic not just among ASHA workers but also their families in an attempt to weaken their of ‘Chalo Assembly’ movement, demanding a minimum salary of Rs 10,000.
But CHWs continue to face harassment and work through poor conditions, and community members have failed to do their bit and cooperate with them, even during an emergency.
The COVID-19 pandemic has brought even the best health systems to their knees. As such, the failings of India’s public healthcare in rural areas owes itself to generations of neglect. So the question arises: when we treat our CHWs so poorly, are we right to expect conscientious work from them? We must take urgent steps are taken to incentivise, train, empower and protect them for this new, and in many ways unprecedented, battle.
And even when the pandemic recedes, we will need to remember that to improve our health care system, our focus has to shift to a primary healthcare approach that goes beyond the usual rhetoric of various policy deliberations. And for that, will need to implement human resource interventions as well as build health and wellness centres, particularly focussed at grassroots-level workers and responding to their specific requirements. To strengthen primary and rural health care, robust, efficient and self-motivated grass-roots worker cadres are indispensable and can no longer continue to be the subject of systemic neglect.
Everything comes down to the basic pillar of healthcare: efficient community engagement.
Apurva Jain is a dentist in Mumbai and an aspiring public healthcare professional at TISS Mumbai.
Accredited Social Health Activist↩