The COVID-19 pandemic would have been far less manageable if not for 2.5 million women Anganwadi workers (AWWs), auxiliary nurse-midwives (ANMs) and accredited social-health activists (ASHAs). These women walked, swum, and trudged across the length and breadth of our country, risking their lives and working over-time to go door-to-door, distributing government relief materials, spreading awareness on COVID-19, monitoring COVID positive patients, and assisting pregnant women. Our overstretched healthcare system stood on the shoulder of these women for not only community engagement but also for starting the largest vaccination drive in the world.
The World Health Organisation (WHO), too, acknowledged their ‘important’ contribution to India’s COVID-19 community outreach programs (IPPPR, 2021). However, despite playing a pivotal role in mitigating the COVID-19 crisis and receiving praises and applause for it, these frontline women health workers continue to be neglected when it comes to legal entitlements and protection. Although there are several policies in place to protect their interests, implementing them is still a big challenge. 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:
Fixed monthly income
In line with the recommendations of the Parliamentary Standing Committee on Labour (2020), ASHAs and AWWs should be recognized 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. Currently, despite being responsible for community-level healthcare in rural areas, immunization, 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 Rs 3,000 to Rs 4,500 per month after a gap of seven years (GOI, 2019). ASHA workers’ earnings 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 a fixed monthly amount to ASHAs, in the range of Rs 2,000 to Rs 6,000 per month, with Andhra Pradesh announcing a hike to Rs 10,000 per month in 2019. Yet, a vast number of States continue with variable pay regimes. Delays in payments of ASHAs are routine across the country (GOI, 2018).
Clear and manageable responsibilities
ASHA and AWWs currently manage multiple responsibilities (child nutrition, women’s health, data collection, immunization, etc.). Under the New Education Policy 2020, AWWs are also expected to contribute to early learning. Apart from that, ASHA workers were not only responsible for sensitizing the rural community about COVID-19, ASHAs and AWWs were deployed for assisting in the execution of the vaccine rollout across the country and also during the vaccine dry-run conducted earlier in the month. Further, they were also sent out to create awareness about the vaccination process among other frontline workers, adding to their already heavy workload (GOI, 2021). Prior to the pandemic, ASHAs were working between 7-8 hours per day. With the addition of new COVID-related responsibilities, this increased by a further 2-3 hours per day, resulting in both physical and mental fatigue (Singaraju and Mandela, 2020).
Therefore, a new organizational framework with detailed job roles and payment bands commensurate with skills and experience and duty hours is required for ASHAs, AWWs and ANMs. An innovative framework can be conceptualized, which (i) offers flexible work hour options; (ii) allows female health workers to specialize in select job roles and areas (e.g. nutrition expert, maternal health awareness expert, immunization expert, new-born care expert, etc.), and; (iii) incentivizes experienced female health workers take up leadership positions such as management of Anganwadi centres and supervision roles in district health programs, as they gather experience. Frontline female health workers should also be considered for appointment to State Health Departments to advise on health programs and policy formulation, given their vast field-level and community knowledge.
Skill-training and certification
Under the current guidelines, AWWs undergo 26 days of training at the start of their service, largely focused on introducing early childhood nutrition and monitoring child health. A large part of this training is theoretical rather than practical or experiential. (Ministry of Women and Child Development, 2018). ASHA workers’ training arrangements are established at the State level, though the National Health Mission has developed extensive materials. ASHA typically undergo 5-7 days of induction training, followed by 16-20 days of thematic training, including fieldwork, mainly focussing on basic maternal health (NHRM Odisha).
Given their ever-expanding role, frontline female health workers need continuous skill training opportunities, either to broaden their skills across disciplines or to deepen their knowledge within an area and move towards an expert level. Within the proposed new organizational framework, work experience and skilling certifications should be introduced to institute seniority levels and specializations. Specialized training, e.g. nutrition, maternal health or early learning, should be offered, linked with higher pay. Most importantly, skill training should be accessible, using audio/video and experiential learning techniques, rather than disseminated in traditional classroom style setups. For instance, the Ministry of Health and Azim Premji Foundation developed an animated, easy to understand, COVID-19 Facilitator Guide Response and Containment Measures Training guide for ANMs, ASHAs, and AWWs.
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 children’s nutritional status between 2018-2019 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 so that they can focus on their core healthcare service delivery, as opposed to lengthy paperwork.
(Views expressed are authors’ personal. Mitali is Founder, and Vidhi is Research Advisor at Nikore Associates, a youth-led economics research and policy think tank.)