Neeta Kashid has no time to rest.
The 44-year-old community health worker's day is filled with visits to women and children in her village in southwestern Maharashtra, India, whom she helps in emergencies and provides maternal and neonatal support.
She also conducts surveys and vaccination campaigns, and acts as the face of the Government's health and sanitation campaigns.
On top of all this, she has to take care of a small farm because she, despite being a full-time healthcare worker, earns less than minimum wage.
“My salary is not enough to survive and I have two children who go to school,” she explains.
Kashid is one of about a million Accredited Social Health Activists known as ASHA, which means 'hope' in Hindi.
They are part of an Indian Government program that serves as a link between rural communities and the public health system.
These women rose to prominence for their role in ensuring access to primary care for poor rural patients when Covid-19 devastated India in 2021, and won the World Health Organization's Global Health Leader Award. Health.
The award has brought more attention to the working conditions of community health workers in India, but also around the world.
In recent decades, community care programs have been praised as a cost-effective way to reduce maternal and infant mortality, HIV, tuberculosis and many other diseases.
But their profitability is due to the fact that these staff, the vast majority of whom are female, are poorly paid, like Kashid, or do not receive any salary, since in many countries it is understood that their work is completely voluntary.
Programs with these types of workers have been praised as a cost-effective way to reduce maternal and infant mortality, HIV or tuberculosis.
But their profitability is due to the fact that these personnel are poorly paid or do not receive any remuneration.
According to a 2022 report by Women in Global Health, a non-profit organization, there are six million unpaid or underpaid female healthcare workers in the world, although this figure is conservative due to the paucity of available data.
The research was based on an article published in 2015 in
The Lancet
magazine in which it was estimated that the unpaid work of community health workers contributed $1.4 trillion to the global economy, implying that the work does not remuneration of health workers, mostly women, was subsidizing almost 2.5% of global GDP at the time.
“Why don't we put a price on this particular labor force and include it in the cost of these programs?” asks Roopa Dhatt, a physician and executive director of Women in Global Health.
“It is exploitation and it must be denounced.”
Indian ASHAs, the accredited health social activists, went on strike last year to demand better wages and a labor statute that includes health and retirement benefits.
A community health worker collecting blood samples in rural Kolhapur, India.
These workers are called Accredited Social Health Activists (ASSA) in India, and are part of an Indian Government program to connect rural and poor communities with the public health system. Abhijeet Abhijeet Gurjar (Abhijeet Gurjar)
Neeta Kashid weighing a baby as part of her routine chores in Mhasave village, Kolhapur district, Maharashtra, a western state of India.
The ASSA program has its roots in a 2002 program that began in Chhattisgarh, one of the poorest states, and was adopted nationwide in 2005. The goal was to tackle child mortality.
Abhijeet Gurjar (Abhijeet Gurjar)
Neeta Kashid conducting a survey during the Covid pandemic in Mhasave village in Kolhapur.
Accredited Social Health Activists were not trained for Covid-19 jobs in India, but were ordered to perform whatever frontline roles were required: reporting, conducting surveys, administering medications, performing medical examinations. ..Abhijeet Gurjar (Abhijeet Gurjar)
Neeta Kashid and her companions visit the village of Mhasave, in the district of Kolhapu (Maharashtra).
Indian Accredited Social Health Activists went on strike last year to demand better wages and a labor statute that includes health and retirement benefits.
Abhijeet Gurjar (Abhijeet Gurjar)
“Community health workers are an anonymous donor, a nameless benefactor to everyone else,” says Madeleine Ballard, executive director of the nonprofit Community Health Impact Coalition.
“In the vast majority of communities around the world, they are the working poor.
In a context of misery and limited access to decent employment opportunities for women, we are not talking about freely chosen volunteering, but rather wage slavery.
I mean you don't volunteer for your community 37 hours a week,” Ballard explains.
In a context of misery and limited access to decent employment opportunities for women, we are not talking about freely chosen volunteering, but rather wage slavery.
I mean you don't volunteer for your community 37 hours a week.
Madeleine Ballard, Community Health Impact Coalition
“The irony is that many of these programs are funded by international organizations that focus their rhetoric on women's empowerment,” adds Ballard.
“And that is used to give moral cover to what they are in fact: programs in which female labor is cheap.”
A job so big that it cannot be paid
”.
The Chinese government pioneered programs with village health workers beginning in the 1930s. The so-called “barefoot doctors” became famous in the 1950s and 1960s, and by the 1970s they had inspired programs around the world. , as the international community coalesced around the goal of providing primary healthcare for all by the end of the 20th century.
The economic crises of the 1980s dealt a setback to the development of these programs, but interest in them was revived in the new millennium, when the HIV pandemic focused attention on providing services to rural communities in the entire African continent.
Community health workers came to be seen as an effective way to reach marginalized and vulnerable populations to address major global public health problems at the time, such as malaria and tuberculosis.
Nowadays, they are going through another promotion cycle after the coronavirus pandemic.
“The amount of money going into hospital care is extraordinary, but the evidence that investing in hospitals improves people's health is simply non-existent,” says Henry Perry, a physician and researcher on community workers at the University Johns Hopkins (USA).
“Scans, open heart surgery or kidney transplants are of course valuable, but they are very expensive compared to the return on investment needed to teach community health workers to diagnose and treat childhood pneumonia or detect hypertension,” he says.
Scans, open heart surgery or kidney transplants are of course valuable, but they are very expensive compared to the return on investment needed to teach community health workers to diagnose and treat childhood pneumonia or detect the hypertension.
Henry Perry, physician and community worker researcher at Johns Hopkins University
The initiative of accredited social health activists in India has its roots in another 2002 program that was started in Chhattisgarh, one of the poorest Indian states, and was adopted nationwide in 2005. The goal was to tackle child mortality.
“ASHAs became a necessity for the services provided by the Government,” explains Sujatha Rao, former secretary of the Ministry of Health and Family Welfare, who participated in the launch of the project. “The main objective was to reduce the levels of maternal mortality and children, which were unacceptably high.”
When the program was introduced, ASHAs' responsibilities were limited to raising awareness, counselling, community mobilization and providing some primary medical care.
Over the years, these responsibilities have increased, as has their schedule: they have gone from working a few hours a week to a full-time workload.
“In 2009, when I joined, we had five to 10 indicators to focus on,” explains Netradipa Patil, a union leader representing more than 3,000 ASHAs in Kolhapur.
“Now, we have 74 indicators.”
Then covid arrived.
While they received praise from everyone for their work on the frontline, the ASHAs received hardly any support.
Kashid was physically attacked by a villager for trying to enforce the Government's quarantine rules.
Another worker, Usha Jadhav, 43, suffered a heart attack, which doctors said was due to irregular meal times and high levels of stress resulting from her work.
For many experts, the struggles of community workers during the pandemic exposed the lie behind a cliché used to justify their lack of pay: that women, by nature, are driven to serve their neighbors and community. , and that paying them would detract from the spiritual benefits of their work.
Researchers like Kenneth Maes of Oregon State University are finding, for example, that far from being in a state of satisfaction and fulfillment, community workers in Ethiopia experience more psychological distress throughout the year compared to other women. people in your area.
It is partly due to the stress of his job and partly due to his precarious financial situation.
“It's emotional blackmail,” complains Margaret Odera of Nairobi, who is working to create a national association of community workers in Kenya.
"People have come to visit us from the United States to tell us, 'You community health workers are doing a great job.'
But when we ask them, 'So are you going to pay us?', they answer: 'We can't, because your work is so big that it can't be paid.'”
The health worker details the health statistics she has compiled for her latest report to her supervisors: children dewormed;
children born in and out of hospital;
Malnourished children;
pregnant mothers;
community members with non-communicable diseases.
And the list doesn't stop there.
Odera remembers that her son once told her: “Mom, you go to the hospital every day.
I think you're a doctor.
But at the end of the month, when I ask you to buy me something, you tell me you don't have money.
What's happening?".
“And you know what?” asks Odera.
“I don't know what to answer.”
This article was originally published in English on
The Fuller Project
.
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