This is their time. After International Women’s day, and in the WHO’s year of the health worker, and in the middle of the pandemic, no one can deny the importance of community health workers. Not just now - our ASHA workers have been key to many of the health system’s successes over the past 10 years, including increased facility deliveries, reduced maternal and infant mortality and vaccination coverage. During the pandemic they have put themselves at risk carrying on their work in communities and villages, ensuring ongoing access to services.
What is key to their success? Obviously their proximity to the community, but maybe also their distance from the formal system.
Everyone acknowledges the excellent work they do, and there are efforts from civil society to reward them more fully – often in the spirit of making women’s work more visible and better remunerated. One way in which many want to honour the ASHA workers is to formalize the cadre.
What does it mean to formalize the cadre? It means to give them a government job.
What a terrible idea.
When we look at many public sector workers in education and the health sector, we see many who are disengaged, demotivated and checked out.* This is a mode of being that is adjacent to depression. When we spend a little more time in these workplaces we often see hierarchical and punitive work environments, with bullying rife. This is absolutely not a secret, nor is it contentious. It’s a truth universally acknowledged – even by the bullies themselves.
One time I asked a friend of mine who is a senior government official why he yelled at his subordinates. He said this was the only tool at his disposal to get them to work as he could not sack them. It seems that total job security can create very negative work environments.
More urgent than a negative work environment: this also leads to sluggish and unresponsive health systems. A sluggish health system does not serve any feminist goals and it does not promote equity generally. Rather the inverse, it’s a very regressive and conservative end-point. It fosters the rise of the private sector and catastrophic health spending.
Nevertheless, a government job bring status to the employee within their family and community, and there is some joy in that. We need to keep in mind though that status and empowerment are absolutely different things.
I don’t see the ASHAs suffering the same work conditions. Their liminal employment status gives them some freedom. When I first came to India in 2010, when the ASHAs were new, my observation was that ASHA workers were all pretty shy and I often just saw them getting barked at by the MO, the DHO or even the ANM. Now, with their confidence increased through their training, their experience and their successes, when I go to the field (in different states and over the years – but I haven’t really been since 2019), they are vocal, confident and speak up to ask questions or provide opinions. I have not seen other cadres such as staff nurses do that in the same way.
In addition, in some workplaces I have been in, for some women their primary sense of responsibility seems to be oriented around their family and ritual obligations – despite salaried employment (for example, doing different pujas at festival time). A liminal CHW work arrangement lets them both contribute to their community, earn money and maintain their many religious and domestic responsibilities, on their own terms. (Should women abide by domestic and religious responsibilities? That is a different question and not the right one for an OCI like me to answer.)
So why would we want to bring ASHAs into the fold of government employment? If there is a dysfunctional mode of employment, I don’t think we should be arguing for women’s increased access to that. That is a dead-on-arrival rallying point.
I think the questions are an opportunity to rethink motivation and engagement of public sector workers generally. What would it take to in terms of workplace contracts or HRH management to create happy workplaces and really bring out the best in all workers? Our teachers and nurses and doctors are all fabulous, but I can’t help but feel like systems are letting them down by providing suboptimal working arrangements that foster disengagement.
This is an area that definitely requires a rethink. I think we need to aim higher - for stronger health systems for all women and for everybody.
What then should we give the ASHAs if not a government job? My dream solution would be to give them the following:
· Remunerate! Increase their regular stipend payments so it is a little above minimum wage if they reach their targets, based on a workload assessment for a 40 hour week.
· An annual bonus of 10k every year if they achieve their outreach goals
· Keep them safe! Give them all health insurance
· Capacitate! Phones or tablets with unlimited bandwidth
· Free access to all-day childcare at the local Anganwadi (with extended hours and including after school care)
· Education grants for their kids’ schooling & books
· Support collective efforts to clarify their needs and maintain demand for these needs, but request that they keep performance as a key priority & bargaining tool.
*In a large World Bank study of 144 countries, the found that the public sector paid higher salaries and had better benefits than the private sector but yet they struggled with motivation because management practices were not taken into account (Hasnain et al 2019)
Thank you to Dr Yamini Atmavilas, Dr Shraddha Chigateri, Dr Indranil Mukhopadhyay. and Dr Rebecca Furth for their discussion and thoughts on this, who all helped strengthen my post through both agreement and disagreement (and sometimes both). I am very grateful to have robust friendships that can accommodate fierce debate - and even more so during the pandemic.