Mumbai: Their average qualification may be Higher Secondary School (HSC/Intermediate) or graduation, but more than 2.3 million of them are responsible for administering myriad government health programmes—from helping mothers with childbirth to ensuring Covid-19 quarantines—and are collectively the frontline of India’s health services.
For millions of Indians without regular access to a doctor, these health workers are the first—and, often, the only—contact with the government health system.
In the post-pandemic era, their responsibilities have grown. Yet, they continue to be paid between Rs 2,000 and Rs 10,000, depending on their states, their jobs are termed “voluntary”, they are supposed to work part-time, and their pay is described as an “honorarium”.
It is no surprise then that two cadres of Indian health workers—anganwadi (government-run creches) workers (AWWs) and accredited social health activists (ASHA)—often protest their sparse salaries, temporary jobs without benefits and lack of legal recognition.
In recent protests, AWWs in Haryana have demanded salary hikes, promotion as supervisors, training to work on the Poshan tracker app (used to monitor and track anganwadi centres and work of AWWs ), payment of salaries on time and regularisation of jobs.
These repeated protests have yielded some monetary and legal benefits, although, as the continuing protests indicate, the health workers regard these as minimal and inadequate.
Some state governments have increased salaries or incentives and courts that once refused to grant them the legal status of employees have now made some concessions.
For instance, the Bombay High Court accorded AWWs the status of ‘workmen’, which means disputes can be taken to industrial tribunals; the Allahabad High Court ordered minimum wages for cooks & helpers with the mid-day meal scheme; and the union government has raised minimum monthly pay of Rs 3,000 by Rs 1,500.
But the overall demands made by both cadres of community health workers over the years remain: reduction in workload, salary hikes, protective equipment, safety from violence from the communities and regularisation, amongst others.
The Vast Remit Of The Health Worker
There are three cadres of community health workers (CHWs) in India: Auxiliary Nurse Midwife (ANM), Anganwadi Worker (AWW), and Accredited Social Health Activist (ASHA) worker.
ANM are women, working under the aegis of the National Rural Health Mission (NRHM) and based at 180,322 nationwide health sub-centres and Primary Health Centres, where they provide basic care, which they also provide during village visits.
The AWW works only in her village or block and provides food supplements to young children, adolescent girls and lactating women. The ASHA worker, too, works under the NRHS only in her village or block, her tasks including the promotion of maternal and child health and contraception, counselling mothers, ensuring immunisations and institutional-based deliveries, for which they receive a performance-related fee.
Envisioned to be village-level midwives, the role of ANMs has transformed to that of a multipurpose worker with a wide range of duties, particularly around family planning and immunization. With 18 months of training, ANMs are the most technically qualified health workers and are supported by ASHA workers, whose work they oversee.
Anganwadis were started by the Indian government in 1975 as part of the Integrated Child Development Services (ICDS) programme, the largest globally, to combat child hunger and malnutrition. AWWs and “helpers” (who support the work of AWWs by cooking, cleaning and serving food at anganwadi centres) are in charge of the 1.4 million anganwadi centres across the country, providing supplementary nutrition, non-formal pre-school education, health and nutrition education, immunisation, health check-up, and referral services, of which later three services are provided in convergence with public health systems.
The New Pressures Of Covid-19
With the Covid-19 pandemic, the responsibilities of health workers increased manifold.
They now were entrusted with community surveillance, door-to-door surveys, educating people about Covid-safe practices, management of quarantine regulations, ensuring home delivery of food and medical supplies and various other ad-hoc tasks to curb contagion.
In Odisha alone, ASHAs and AWWs helped the government identify 115,000 Covid-19 cases in two months through door-to door surveys, monitoring and follow-ups.
During Covid-19, the tasks of monitoring and conducting syndromic surveys, disease surveillance, data reporting, public health messaging, delivering essential food and ration services fell primarily on India’s health workers, according to a 2021 study of 201 female healthcare workers conducted across 10 states by Behan Box, a journalism website focussed on the issues of women and gender-diverse persons.
All three cadres routinely worked for more than 12 hours a day. They reported feeling alienated and undervalued for the disproportionate workload without adequate pay, personal protection, and state support.
Another study by the Economic Research Foundation, a not for profit think tank, of women front-line workers in Telangana and Bihar, revealed the hardships they faced pre and post Covid-19. The study pointed to systemic apathy towards AWWs and ASHA, both of whom are considered ‘volunteer workers’ and paid a honorarium, as we said, unlike ANMs who are government rolls and receive a salary.
The Demand For Dignity Of Labour
After much agitation by the AWWs unions in 2018, the central government raised the minimum pay for AWWs from Rs 3,000 to Rs 4,500 per month. State governments supplement this from their own funds, if they want to.
For example, Telangana pays AWWs around Rs 10,000 per month and Bihar pays an additional Rs 750 per month. ASHA workers are paid an incentive. In 2018, the routine and recurring incentives for ASHAs under NHM was fixed at Rs 2,000 per month. While some states pay a fixed amount to ASHA workers, others do not pay even the minimum wage.
Although the union government has mandated 180 days of maternity leave, two sets of uniforms per year, and insurance, benefits and entitlements for AWWs vary from state to state. Kerala, for example, provides AWWs with a pension, marriage assistance, medical aid and other benefits through a welfare fund.
AWWs and ASHA workers across different states have time and again unionised and agitated against their working conditions. One of the workers’ key demands is a hike in pay.
At the core of the demand for better pay is another critical issue unique to AWWs and ASHA workers: their volunteer status. As workers of welfare schemes, these workers have invariably had to face push back for many of their demands because of the institutional stand that their work is ‘voluntary’ and thus their pay is only an ‘honorarium’.
For years, the government has maintained its stance on the status of AWWs and ASHA workers as honorary workers. As per this argument, AWWs and ASHA workers are ‘part-time’/volunteer workers, spending a few hours each day on their tasks and that treating them as government employees would negate the basis of the schemes.
The reality is that the role of AWWs and ASHAs, with the numerous additional responsibilities, particularly, after the pandemic, has proven to be critical to India’s healthcare and food-security systems.
The 45th session of the Indian Labour Conference (ILC) held in 2013 recommended that all scheme workers be recognised as ‘workers’ and not ‘volunteers’ or ‘honorary’ workers, be paid minimum wages and receive statutory benefits.
The Standing Committee on Labour 2019-20 recommended that the Code on Social Security include AWWs and ASHA workers in its definition of ‘employee’. The 2020 code, which aims to extend social security to all employees and workers either in the organised or unorganised sectors, excludes ASHA and AWWs.
The Law And AWWs And ASHA workers
The courts have also not proved to be of much support for these workers and their demand for minimum wages and recognition as employees of the government.
The Supreme Court in 2006 held that AWWs do not hold any civil post and thus the recruitment rules ordinarily applicable to the employees of the state do not apply to them. The court also held that they are not covered by the Minimum Wages Act, 1948, because the Act specifies the industries it is applicable to and the ICDS program is neither an industry nor are AWWs considered industrial workers.
Lower courts nationwide, including in Delhi, Gujarat and Jammu and Kashmir, have reiterated the stance that AWWs do not hold a civil post or cannot be considered ‘workmen' under the Industrial Disputes Act, 1947, which has meant that AWWs have no remedy at Administrative Tribunals or Labour Courts.
However, in terms of recognition of the workers, the Bombay High Court in 2010, in line with the Supreme Court's jurisprudence on AWWs not holding a ‘civil post’, held that AWWs are in fact 'workmen' within the Industrial Disputes Act, 1947.
The Bombay High Court added that in the state of Maharashtra, AWWs could approach the Industrial Court in their district and/or the Labour Court under the Maharashtra Recognition of Trade Unions & Prevention of Unfair Labour Practices Act 1971. Although this has come as a relief, the impact of this recognition needs to be felt on the wages and benefits to which AWWs and helpers are entitled.
In 2018, two private members bills were introduced in Parliament to regularise AWWs and ASHA workers. While the bill extended to only union territories, it aimed to confer the status of employees to the workers and would entitle them to the tenure, terms, and conditions of service including remuneration, leave, provident fund, retirement, and other terminal benefits as are available to Group “D” (AWWs) and Group “C” (ASHA workers) employees of the union government.
The bills did not see the light of the day but were, undoubtedly, a step in the right direction.
A Welcome Step And Way Forward
In what has popularly come to be known as the Right to Food case, the Supreme Court took an expansive stand and ordered that “in the appointment of cooks and helpers, preference shall be given to Dalits, Scheduled Castes and Scheduled Tribes”.
Cooks cum helpers (who mostly belong to marginalised communities) as per the Supreme Court order, have not had any formal recognition and are paid a minimum of only Rs 1,000 per month for only 10 months as ‘honorarium.’
This minimum amount is shared between the Centre and states (except northeast states, where the share between Centre and the state is 90:10) 60:40. As with AWWs and ASHA workers, even though some states have chosen to supplement this minimal amount from their pockets, the average across states averages about Rs 1,500 per month, with some paying Rs 1,000, others Rs 2,000 to Rs 3,000 and a few outliers, such as Kerala, which pays up to Rs 9,000.
In December, 2020, the Allahabad High Court granted some relief to cook-cum-helpers, ruling that they were entitled to minimum wages, encouragement for AWWs and ASHA to petition the courts and continue protests.
The Covid-19 pandemic has brought to light the need to strengthen healthcare and food security especially among marginalised communities.
About 189 million Indians were undernourished before the pandemic, and after a series of lockdowns, half of rural households reduced the number of daily meals and 68% reduced the number of food items in their meals, according to a May 2020 study.
Yet, many of those who got by did so because of the role played (here and here) by those on the ground ensuring the last-mile delivery of services. The need to recognise unpaid work and restructure the labour market to ensure inclusion for community health workers will be a long battle. Ensuring their dignity is a start.
(Devika Nair is a candidate for a MPhil in human rights at the University of Oslo and founder and director at NyāyaSarathy Foundation, an organisation working towards increasing access to justice for marginalised communities. Sumati Thusoo is an extramural research author at the department of sociology at Monk Prayogshala and founder and director of NyāyaSarathy Foundation. Drasti Jain is a penultimate year law student at the Government Law College, Mumbai.)