High Risk without Recognition: Challenges Faced by Female Front-line Workers
An already overburdened, understaffed and under-resourced health system faced severe repercussions in the wake of the pandemic. Those at the forefront of health and nutrition service delivery at the community level are struggling due to increased work burden and low compensation received, particularly since most of them are not formally recognised as workers. In this article, we discuss the conditions of work of front-line women workers, especially accredited social health activists, anganwadi workers and their supervisors (Integrated Child Development Services supervisors, auxiliary nurse/midwife and ASHA facilitators) in the context of the COVID-19 pandemic. Based on interviews conducted with workers in Telangana and Bihar, we highlight how women front-line workers were overworked and underpaid even before the pandemic and continue to remain so even after.
The COVID-19 pandemic has presented a unique opportunity to highlight the working conditions of the vast reserve of women front-line workers employed under various government schemes in India. Such workers play a critical role in the government’s efforts towards improving human development outcomes. Globally, this role has been recognised as being crucial for better implementation and outreach of health services to the population. However, most women engaged in front-line public services in India are considered volunteers and not full-time government employees. Instead of monthly salaries, they are paid honoraria or provided task-based incentives (which are often below minimum wages).
During the novel coronavirus pandemic, the prominence of such all women cadres has assumed new proportions. Since the beginning of the nationwide lockdown to curb the health crisis in March 2020, these female workers have undertaken a broad range of tasks. This includes conducting surveys, making door-to-door visits, assisting with contact tracing, testing and spreading awareness. Needless to say, they have contributed not only towards curbing the spread of the infection but also in helping people to access treatment in both urban and rural areas.
In this article, we discuss the conditions of work of front-line women workers, especially accredited social health activists1 (ASHAs), anganwadi workers2 (AWWs) and their supervisors (Integrated Child Development Services [ICDS] supervisors, auxiliary nurse/midwife [ANMs] and ASHA facilitators) in the context of the COVID-19 pandemic. Based on interviews conducted with workers in Telangana and Bihar, we highlight how women front-line workers were overworked and underpaid even before the pandemic and continue to remain so even after.
The article is based on background data from government department websites, data from a (phone) survey conducted between July–August 2020 with 375 women front-line workers in Bihar and Telangana (details in Table 1) and in-depth interviews conducted with front-line workers between May–August 2020. Given the constraints imposed by the pandemic, the sampling was not randomised rather based on the availability of respondents’ contact information and willingness to respond to phone interviews. Therefore, the data are not representative of either the department, the cadre or even the state. However, they are valuable in highlighting the conditions of work of these front-line workers as well as giving an idea of how their roles were affected because of the COVID-19 pandemic. Most of the findings are also validated by a number of newspaper reports, and other primary surveys that have been conducted with these workers (Rao and Tewari 2020; Srinivasan et al 2020).
Table 1: Number of Respondents by Designation
|Nurse (in PHC)||0||8||8|
Our findings show that even during the pandemic, while the workers were given additional responsibilities, few were given protective gear or transport facilities. In fact, it was seen that the workers closer to the ground were the ones who got least support. The higher-level staff who were regular employees were able to demand better facilities in terms of personal protective equipment (PPE) as well as transport arrangements. This broadly translates to little acknowledgment of the crucial work they participate in. This is clearly reflected in the multiple strike calls given by ASHA workers from local to national levels, during 2020 alone, demanding better conditions of work (Dayashankar 2020; Times of India 2020).
While there were common themes in terms of work conditions found in both the states, there were also differences in certain aspects, with a relatively better situation in Telangana. The health and nutrition outcomes in Telangana are also much better than in Bihar, and so is the overall standard of living and education levels. Telangana also has better conditions of work and a significantly higher female labour force participation rate compared to Bihar. Based on this study, the authors comment on how women, as well as the community, perceived their roles and the status that they enjoyed, and how these perceptions varied by state. The starkest contrast between the experiences of women front-line workers across both states lies in the pay scales that apply to them, as seen above, with honoraria-based workers in Bihar getting paid almost half of what is paid in Telangana. As a result, women in both states had differing views on the importance of the work they did. Anganwadi teachers (AWTs) in Telangana identify themselves as teachers and value their contribution to society. Even ASHA workers who are paid a base salary consider themselves regular government workers. There was also a difference in the way women perceived the opportunities available to them across the two states. Therefore, the responses of the women also need to be interpreted with reference to their contexts.
Pre-COVID-19: Overworked and Underpaid
Despite their voluntary worker status, the multiple roles and responsibilities that ASHAs and AWWs are given often amounts to a full day’s work. Previous literature especially in relation to anganwadi workers have also pointed this out (Dasgupta et al 2012; John et al 2020). This is also seen in their official job descriptions in both states. AWWs’ tasks, both in Telangana and Bihar, ranged from conducting regular health surveys of families, maintaining files and records, running the anganwadi centres to spreading awareness on health, nutrition, family planning, and child growth and development. They are responsible for keeping track of immunisation of children as well as providing preschool education. These workers are further responsible for the implementation of schemes related to adolescent girls.
On the health front, ASHA workers play a key role in the healthcare apparatus as links between public healthcare delivery systems and the community they serve. According to the National Health Mission guidelines, their principal tasks involve creating awareness and providing information to communities on matters of nutrition, sanitation, hygiene, family planning and existing public health services.3 They are involved in counselling women and their families on birth preparedness, breastfeeding, immunisation of infants, health and contraception. ASHAs also accompany pregnant women and children requiring treatment to the nearest health facility (such as a primary health centre [PHC], community health centre or first referral unit). Like with the AWWs, their job description keeps expanding to include more tasks. During the interviews, almost all of them spoke of the multiple tasks that they have to do on a daily basis. None of them perceived it as “voluntary” work that could be done based on how much time they had, rather as duties that any regular employee has to perform.
Other than the regular defined tasks, ASHAs and AWWs routinely have to take on other work (from other government departments) beyond the scope of their roles. For example, one of the ASHAs in Telangana mentioned that recently during the rainy season, to prevent spread of dengue and malaria, they had to go fishing and put those fish in wells or in any unused water where larvae are more. Surveys, electoral lists and health campaigns are also delegated to them depending on government requirements.
The burden of work on these women is not something that would qualify as being part time or voluntary (Jain et al 2020). Our survey also showed that many worked on average six hours or more a day before the COVID-19 pandemic (refer to Table 2). Even among ASHA workers who are incentivised on a case-by-case basis, more than a quarter had a full working day, and a further 46% said that on an average they worked four to six hours a day. It is therefore clear that even for women working as ASHAs it is not possible for them to work elsewhere for an income, such as agriculture or non-agriculture labour while doing this job. Ninety percent of AWWs also worked more than four hours a day, with around 60% saying they worked more than seven hours a day.
Table 2: Average Working Hours in a Day (% of Total Respondents)
|Designation||Less than 4 hours||4–6 hours||7–8 hours||More than 8 hours|
Data on vacancies in supervisory positions in both ICDS and health also show that inadequate staff is a huge problem restricting the ability of those who are present to actually provide any supportive supervision. As of July 2020, the number of vacancies in supervisory positions for ICDS stand at 46.3% in Bihar and 41.3% in Telangana.4
Despite being overworked, women in these roles are also overwhelmingly underpaid. Owing to their “honorarium” based employment status, their monthly income in Bihar ends up being even less the wages of unskilled manual labourers under the Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA) in the state.5 In the case of ASHAs, the initial design of the programme itself was such that they were paid incentives for different tasks undertaken by them with no fixed wage component. However, over the years with the number of tasks being given to ASHA workers, they have begun to organise themselves and demand recognition as employees. The Indian government recently increased the incentive package for ASHA workers in such a manner, where it states that each ASHA worker will get at least ₹2,000 per month (PIB 2018). Some states have also started giving a fixed component to ASHA workers. In Telangana, for instance, ASHAs are paid a wage of ₹6,000 a month. In Bihar, on the other hand, ASHAs in the state have no fixed wage component and earn purely on the basis of incentives. Further, the new incentives have not yet been implemented in Bihar. Therefore, the disruption in immunisation services and difficulty in accessing health centres during the lockdown actually meant a significant decrease in incomes despite more work.
Even in the case of AWWs, there is a lot of variation in what they get paid in different states. In 2018, the central government nominally increased its contribution for AWW honorarium to ₹4,500 from ₹3,000 per month. States top this up from their own budgets. Bihar pays an additional ₹750 per month while in Telangana they get ₹6,000 more as the state contribution. Their salary in Telangana of ₹10,500 a month is much higher. Even though it is still less than what a regular employee in the government would get, this definitely adds to their self-worth.
Needless to say, income levels also reflect in the women’s perception of their work, self-worth and standing in their community. In the case of AWWs, the government has consistently argued that they are not employees and are “honorary” workers and therefore the laws related to minimum wages and other labour rights do not apply to them. This argument also was withheld by the Supreme Court in a case filed by the Karnataka AWWs union (PIB 2014). To make matters worse, they have to cope with delays in payment, poor infrastructure and transport and so on. The survey found that only 45% of the respondents in Bihar had been paid in the last two months, and for the rest their salaries had been delayed for over two months. In Telangana, the salaries were more regular.
Post-COVID-19: Amplified Impact on an Already Overburdened System
The onset of the pandemic increased the burden of work especially on ASHAs manifold and they had to face greater logistical hardships relating to transport, infrastructure and payment. The additional responsibilities related to the pandemic that these front-line workers were given included awareness campaigns, surveys, home delivery of supplementary nutrition and other services, making quarantine arrangements for returning migrants and arranging for relief measures (such as public distribution system rations) to reach beneficiaries. With anganwadi centers closed, AWWs had to home-deliver supplementary nutrition and also check on high risk pregnancy cases every day. Additionally, during the lockdown they, along with ASHA and ANM, were responsible for doing door-to-door surveys and spreading awareness on wearing masks and washing hands.
During COVID-19, ASHAs were supposed to get an incentive of ₹1,000 per month for the additional amount of work that they were having to do. None of the respondents in either of the states had received this additional payment at the time of the survey and interviews (July–August 2020). While in Bihar there were massive delays in payments, in Telangana they were receiving their regular wages on time but AWTs were faced with a 10% cut in salary due to COVID-19. In Bihar, the ASHAs were given ₹200 a day for door-to-door survey, but there was a limit imposed that the survey had to be completed in three days even though it actually took longer.
When asked about her additional work, Ankita, an ASHA worker from Samastipur, said, “we had to conduct this survey in our wards only and daily go for 4-5 days to see where who has come from, whether anyone has a cold is coughing or sneezing, who has come from outside among them or whose having breathing difficulty and these signs we had to check in the houses we had to cover; we had to ask questions and fill the forms that had come from the block office.” Owing to pressure from government officials, they often worked over time.
The pandemic also entailed a greater burden of domestic work. According to one respondent, “we used to leave the house in the morning at 8 am since there were a lot of house visits to do and we would do all the work and return around 5-5.30pm in the evening on those days. We never stopped for any breaks, just stood and finished the work as fast as we could or we would not be able to fill the forms if we did not make it to the houses,” she said. Needless to say, her day included waking up early in order to complete all her household chores. Her three children and husband were all home during this period and she was required to wash clothes, cook lunch and dinner for them before leaving for the day’s work and then again return to complete the remaining work. Among the phone survey respondents, 42% (44% in Bihar and 40% in Telangana) felt that they had more work than usual (refer to Table 3).
Table 3: Responses Comparing Work Post-COVID-19 With Pre-COVID-19 Scenario (% of Total Respondents)
|More than usual||43.8||39.7||42.1|
|Same as usual||15.2||47||28|
|Less than usual||41.1||13.2||29.9|
Note: N is the total number of respondents.
Even among those who said that the quantum of work did not increase, there was a greater pressure during this period given the overall environment of the spread of the infection in which they had to continue working being constantly in touch with a large number of people. At the same time the workers also talked about the difficulties they faced in doing their regular tasks. In Bihar, for instance, ASHA workers talked about being unable to take people to the PHCs due to the lack of public transport.
The imposition of a strict lockdown accompanied a strict halt in all local transport services. Local trains, buses, autos and all other forms of transport were unavailable. Most married AWWs, ASHAs and ANMs (in both states) we spoke to looked for support from their husbands for mobility during this period, to travel for meetings, taking patients to the PHC and so on. Transportation was a huge problem for single women like Balamma, who works as an anganwadi supervisor. She says, “Buses were not there. I faced a lot of problems. But they told us that we have to definitely go to villages. It is the Collector’s order. I am a single woman (vontara mahila). I do not have any male companions. I do not have a husband or father to take me and drop. If there is a vehicle/bus, we will go in it. When it’s not there, how should we travel?”
Many also faced additional pressure from their households to stop doing this work as it is seen to be too risky with few benefits. Rajita, who is an ASHA worker from Telangana, gave her entire earnings to her husband and had no access to cash. Until June 2020, she was not given a single mask and she used to do surveys by tying her handkerchief over her face. Her family was against her working during this (pandemic) time. She recalls, “My mother-in-law used to ask me to not go again and again. But when there is a job, we must do all this! So, I used to just go. They got angry with me and didn’t buy me a mask or sanitiser!”
Community members were also hostile towards these health workers owing to the fears of being forcefully quarantined in government facilities. People often stopped them from entering their homes and made them stand outside while answering their questions for fear that they may infect them. Murdeshwari (an ANM from Telangana) recalls, “People did not even give us a glass of water! They said that, if we come close to you or give you water, we might get it. They locked their door, and used to talk from a distance. But this is our profession! If we get it, we can still deal with it. But they should not get it from us. At first, I felt bad, but then it became normal.”
Preeti, an ICDS supervisor from Bihar, adds that despite taking so much risk during the pandemic, the government still refuses to recognise their value and pay them better. She says, “on one hand the government wants to empower women and on the other not pay them. Under the Women and Child Development programme you have given a woman work but that woman is malnourished and not getting paid. During this lockdown, so many women bought their rations with interest from shops. How will they manage their houses? And their families are objecting to their leaving the house during the lockdown and will not even give them any money, then who will see to their problems?” In Bihar and Telangana, workers were paid ₹200 per day with a three-day limit to undertake ward-wise surveys of the population. This at a time when most incentive-based ASHA work was stopped, thereby reducing their income.
Access to Protective Gear or Support
Despite the higher risk of contracting COVID-19, front-line workers had limited or no access to basic PPE, such as masks, gloves and hand sanitisers, let alone visors and scrubs. While a large proportion of the phone-survey respondents reported that they had received protective gear (refer to Table 4), the qualitative interviews revealed that this distribution was a one-time supply. Furthermore, the gear provided was not of a good quality, because of which workers had to make their own arrangements.
Table 4: Received any Protective Gear (% of Total Respondents)
|Designation||Bihar (N=224)||Telangana (N=151)|
Note: N is the total number of respondents.
According to Malti, an ANM, “what they gave only functions for 4 hours! We buy and wear our own masks! They gave in March of 2020 but only about 10 of each. That is not enough and we bought from outside. Even the sanitisers they gave us were about 200ML! That is not enough so we bought more personally.” Sonia (AWW, Vaishali) also mentioned that neither AWWs nor AWHs in their area were given any masks, gloves or sanitisers from the CDPO office. She resorted to covering her face with cotton cloth material from her house.
The poor conditions of work pre-COVID-19 were only further exacerbated post the pandemic. While there is a huge scope of improvement on both states, Telangana was relatively better when compared to Bihar on many counts.
Many of these women workers have spent years demanding recognition as government employees performing crucial full-time jobs as front-line health workers. However, their demands have been ignored so far, except for in some states such as Telangana where there has been a broad-based increase in honorariums. 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.
The central role that these workers have been playing in the COVID-19 pandemic could become an opportunity for recognition of their work and initiate a process where their work conditions are improved. Expanding better opportunities with decent wages for front-line workers is not only necessary for acknowledging their rights as workers, but could also contribute to the revival of the rural economy by putting wages into the hands of many, and take us closer to achieving our health and nutrition goals. This is especially important in the current context where employment opportunities for educated rural women are so few.
Given the declining female labour force participation, the government’s recognition of front-line workers and their contribution to human development is an urgent requirement. AWWs and ASHAs (alongside supervisors and ANMs) deliver services crucial to the health and well-being of the population. The chronic lack of attention to their working conditions only serves to weaken policy outcomes, women’s empowerment and community development over all.
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