FEMALE FRONTLINE COMMUNITY HEALTHCARE WORKFORCE IN INDIA DURING COVID-19

REPORT BY BEHANBOX www.behanbox.com P r i n c i p a l I n v e s t i g a t o r s

B h a n u p r i y a R a o , F o u n d e r - E d i t o r , B e h a n B o x S r e y a D u t t a C h o w d h u r y

R e s e a r c h C o n s u l t a n t s

A i s h w a r y a A g a r w a l S h a i l y A g r a w a l S h u b h a n g i D u b e y A y e s h a H u s s a i n E i s h a H u s s a i n N o l i n a S M i n j R a n j i t h a M u n i r a j Y a s h a s h w a n i S r i n i v a s D e v i k a S h e t t y S h u b a s h r i C h o w d h u r y U d i t a H a l d e r K a u s u m i S a h a S w e t a D a s

D a t a A n a l y s i s a n d V i s u a l i s a t i o n S h u b h a n g i D u b e y

R e p o r t D e s i g n M e g h a G a r g TABLE OF CONTENTS

01 Table of contents

02 Acknowledgements

02 Abbreviations

03 Executive Summary

Main Findings

10 Burden of Work

14 Salary and Honorarium Payments During The Pandemic

19 Debt Among Healthcare Workers During The Pandemic

22 Medical Apathy and Deaths On Duty

23 A Culture of Bribes

24 Training For Healthcare workers

25 Facilities For Healthcare Workers

26 Physical Health of Healthcare Workers

28 Mental Health of Healthcare Workers

29 Protective Equipment

31 Discrimination and Violence On Healthcare Workers

33 Coordination Among the Cadres of Healthcare Workers

34 How Data Flows In the Healthcare System

36 Demands : 1.ASHA Workers 2.Anganwadi Workers 3.Auxilary Midwives Workers

40 Bibiliography

0 1 Acknowledgments

BehanBox is a platform for in-depth, investigative and research driven journalism on gender issues. We have been reporting on the state of healthcare workers in India since the beginning of the pandemic.

This research across 10 states on the role of female frontline healthcare workers during the Covid-19 pandemic was made possible by a generous grant from the Azim Premji University. At BehanBox, we express our sincere gratitude to the Azim Premji University and the Covid-19 Research Team to enable this important research.

Our deepest gratitude to all the 201 female healthcare workers who gave us their time for in- depth interviews despite their busy schedules and Covid-19 duties. They opened up and allowed us to enter into some very sensitive areas, such as debt and mental health, in the hope that our study is able to drive positive policy action from the government.

We also thank our researchers whose empathetic as well as deep interviews gave us a very insightful peek into the healthcare workers and their interface with the healthcare systems. Their interviews captured the nuances of the lives of healthcare workers that otherwise remain invisible to the state and society. Finally we would like to thank the Covid-19 Research team at Azim Premji university for their constant support and very engaging ideas. We would particularly like to thank Dr. Harini Nagendra, Ms. Padma Nayar, Mr. Shashwat DC and Mr. Vergheese.

Abbreviations

ASHA Accredited Social Health Activist AWW Anganwadi Worker AWC Anganwadi centers AWH Anganwadi Helper ANM Auxiliary Nurse Midwives DAWA Delhi ASHA workers’ Union ICDS Integrated Child Development Scheme MCTS Mother and Child Tracking System MoFHW Ministry of Health and Family Welfare NRHM National Rural Health Mission NFHS National Family Health Survey PHC Primary Health Centers PPE Personal Protective Equipment

0 2 Executive Summary

1 million Accredited Social Health Activists (ASHA), 2.6 million Anganwadi workers (AWWs) and an entire cadre of Auxiliary Nurse Midwives (ANMs) have been at the forefront of Covid-19 response system in India. The three cadres of female frontline health workers, for decades, have been engaged in strengthening primary health care outreach and community nutrition programs across the country. While their work has been crucial to India's health care system, they have often been underpaid and undervalued.

During the pandemic, the task of monitoring and conducting syndromic surveys, disease surveillance, data reporting, public health messaging, delivering essential food and ration services to keep hunger and malnutrition at bay among their routine tasks, fell on these three cadres of workers at the community level.

During the pandemic, all 3 cadres routinely clock over 12 hour work days and are on call the rest of the time, reported feeling alienated and undervalued for the disproportionate burden they bear in India’s battle against Covid-19 without adequate pay or indeed personal protection and state support. India's pandemic response was heavily reliant on the underpaid, undervalued and invisible labour of its community healthcare workforce.

In the first of its kind study in 10 states across India, we explore the role of ASHA, Anganwadi and ANM workers during the pandemic, the economic vulnerabilities, the physical and mental health burdens of the workers and most importantly, the crucial demands of the health care workers for an adequate policy response by the central and state governments.

The study was conducted in the states of Assam, Bihar, Haryana, Jharkhand, Karnataka, Maharashtra, Madhya Pradesh, Delhi, Telangana, and Uttar Pradesh.

0 3 Summary of Findings

Through information gathered from interviews with 201 frontline health workers across the 3 cadres, here is an overview of study findings.

Burden of Work: All three cadres of workers reported a higher burden of work and field duties during the pandemic. ASHA and AWWs have been responsible for the bulk of Covid-19 related surveys, policing of quarantine centres, monitoring of containment zones, distribution of food rations over their regular set of non-Covid tasks. On an average, work hours have increased from 6-8 hours a day to almost 12-15 hours of work per day, while being on call for almost 24 hours.

Drop In Incomes: ASHA workers who receive incentive based honorariums saw their incomes drop between Rs 1000-5000 during the pandemic due to suspension of routine tasks such as immunization, pre and ante natal care etc. 86% of ASHA workers reported a drop in their incomes during the pandmeic due to loss of incentives. ASHAs reported not receiving many incentive components corresponding to all the tasks they carry out. Central government mandated Covid-19 incentive of Rs 1000 between January to September, over 31% of ASHA workers we interviewed said they had not received the incentive yet. Many respondents among ASHA, AWWs and contractual ANM workers reported experiencing an average delay of 1-6 months in receiving their remuneration.

Debt Burden: ASHA and AWWs reported experiencing debt burden due to inadequate remuneration and delay in payments amidst job losses in their families. The recorded estimates of debt burden range between Rs. 10,000 to even Rs 1,00,000 among ASHA and AWWs. The pandemic has exacerbated debt situations as many have had to invest in android mobile phones for their children’s online classes, out of pocket expenditure for protective gear , in food and medical expenses even as there has been an overall loss in family income during the period of lockdown. 19% respondents recorded that they have sold household assets and pawned jewellery to meet expenses or borrowed from self-help groups, family members, co-operative banks for loans.

Protective Equipment: During the pandemic disbursal of masks, gloves and sanitizers for health workers by the government has been inadequate. At the time of interviews, 28% of healthcare workers had not received PPEs at all from the government. ASHAs and AWWs in most districts across all states noted that they received safety kits only 2-3 times since the beginning of pandemic duty in March 2020. In many districts, ASHA, AWW and ANMs reported stitching masks, buying soap and sanitizers for personal use as well as community distribution.

0 4 Discrimination and Violence against health workers: Frontline healthcare workers have reported instances of discrimination and violence both from within the community and other healthcare staff and government officials including the police during the pandemic. There have been many recorded cases of assault on ASHA workers by community members especially in Haryana, Delhi, Telangana, Uttar Pradesh ASHA workers. The pandemic has also worsened existing, caste, religious and ethnic tensions existing between communities.

Covid Deaths: Several ASHA workers in Bihar, Madhya Pradesh, Delhi, Assam and Jharkhand have reported to have died, either due to Covid-19 infection or mishaps such as road accidents and even exhaustion while doing their healthcare duties. Insurance payouts to their families have been hard to come by.

Mental and Physical Health: The bulk of Covid tasks has impacted physical health of workers. Many reported loss of weight, body pain, fluctuating blood pressure and haemoglobin levels. Fear of infection and debt burden has exacerbated anxiety and stress levels, adversely impacting mental health of ASHA and AWWs.

Background of Community Health Worker Programs

Auxiliary Nurse Midwives: The post of the Auxiliary Nurse Midwife was created as early as 1952, for addressing maternal health, midwifery and child health services. However, the violent imposition of sterilization measures during the 1970s overseen by the Indira Gandhi regime marked a shift away from narrow focus on family planning as a public health policy. Initially imagined as primary agents of family planning services, since the 1970s, the mandate of ANMs began evolving to include a range of preventive and curative services at the village level. With the expansion of their role, ANMs transitioned from temporary to permanent staff within the health system and were reclassified as female Multi-purpose Workers (MPV). In the rest of the report, we refer to this cadre of workers as Auxiliary Nurse Midwives (ANMs).

Anganwadi Workers: India’s Integrated Child Development Services program (ICDS) was established in 1975 after an inter-ministerial survey in 1972 revealed that child care programmes in India were not having the desired impact. The Anganwadi worker- a community health worker empanelled with the ICDS- was instituted with nutritional care of communities, particularly pregnant women and children between the ages of 0-5 years. At present ICDS is estimated to be the world’s largest integrated childhood program.

0 5 ASHA Workers: The Accredited Social Health Activist Scheme (ASHA) was an important intervention of the National Rural Health Mission (NRHM) launched as a public health program in 2005. ASHA workers, within the NRHM program have been envisioned as elected community members who help implement the various components of the programme. ASHA workers, form the world’s largest community healthcare workforce and have been instrumental in improving maternal and child health outcomes and reducing the communicable disease burden in India.

Literature Review

Health systems and planning in India have been explored in great detail in social science literature, with contributions from public health experts, community medicine practitioners, civil society actors. (Amrith 2007; Banerjee 2004) In delineating the political culture of health system initiatives in post independent India, Amrith (2007) and Banerjee (2004) note that leaders of newly independent India had ambitious plans for instituting nation-wide public health care systems. The discourse of health as socially determined and public health as a matter of state concern, as a nationalist project that would liberate the massed of oppressed, colonized people was manifest in 1946 Sir Joseph Bhore Committee Report. The Bhore Committee report as part of the first Health Survey and Development Committee established in 1946, gave the impetus for setting up Primary Health Centres that would provide holistic preventive and curative care to entire rural populations.

In this context, we note that India has three cadres of women health workers’ Auxiliary Nurse Midwives, Accredited Social Health Activists and Anganwadi workers who are responsible for primary health care services and communitization of health care.

Several authors who have evaluated the functioning these community health worker programs have highlighted issues pertinent to the performance of these three levels of cadres. In the context of ASHA workers, Banerjea (2018) notes that they are treated as voluntary care-givers whose work is trivialized as low-skill women’s work. Gaitonde et al (2017) note, while ASHAs were originally envisioned as community activists within the National Rural Health Mission (NRHM), they have an underwhelming role engaging with systemic issues of the health system in the villages. As outliers in the official medical staff hierarchy in the NRHM, they have little bargaining power with staff at primary health centres, hospitals and dispensaries.

0 6 Very few studies have been done evaluating the outcome of the ANM program. In a placebo- controlled trial conducted between 2002 to 2005, among 1620 ANM functionaries, Derman et al. (2006) note that ANMs facilitated 5.6 % reduction in maternal mortality, by effectively administering oral misoprostol to reduce rates of acute postpartum hemorrhage and acute severe postpartum hemorrhage. Agrawal et al. (2012) found that coverage of antenatal home visits and newborn care practices also increased with proper training of ANMs. ANMs are mandated to remain on call 24 hours a day but due to security issues, inadequate facilities at the sub center and family pressure, ANMs are unable to provide 24-hour medical assistance Iyer and Jesani (1995) have noted that ANMs face issues of security at the medical subcenters. Mavalankar and Vora (2008) highlight the problem of “nonresident” ANMs, as many ANMs choose to not spend their entire day in the subcenters which impacts their readiness to respond to emergencies.

In the context of Anganwadi workers, John et al (2020) note that the performance of AWWs is impacted by organizational factors such as availability of program resources such as food rations at the Anganwadi centres, systemic corruption and caste dynamics of a particular region The authors note that individual factors such as financial remuneration play an important role in the participation and performance of all three cadres of workers. (John et al 2020) As a result, programmatic changes such as better remuneration, improved working conditions and supportive management are vital for better outcomes of health worker schemes.

In the backdrop of this existing literature we have evaluated the role of these three cadres of workers during the Covid-19 pandemic. In doing so we contribute to existing literature on community health worker programs from the vantage point of an ongoing pandemic. All three cadres have been directed towards Covid duty and have been pivotal for pandemic prevention and control. We note that issues of caste discrimination, physical security, payment and training continue to impact community health worker programs. In the Covid-19 context we further explore work burden, debt burden, physical violence, availability of safety equipment and other issues that have impacted workplace experience of ASHA, ANM and Anganwadi workers. We also explore the specific ways in which all three cadres of workers have been carrying out their tasks during the pandemic.

0 7 Research Methodology We have adopted a mixed methodology approach to obtain qualitative narratives as well as quantitative data on key issues pertinent to work and wage situations of ASHA, ANM and Anganwadi workers during the pandemic. As tools of research, we administered separate interview schedules for each category of worker. We also created separate questionnaires for Union leaders among ASHA, ANM and AWWs to elicit specific information on data flows and chain of hierarchy among health workers.

Our study was conducted in 10 states: Assam, Bihar, Haryana, Jharkhand, Karnataka, Maharashtra, Madhya Pradesh, Delhi, Telangana, and Uttar Pradesh. All our interviews were telephonic due to the pandemic and widespread nature of our sample.

We have conducted qualitative interviews on the burden of work, payment, debt, toll on mental and physical health of frontline health workers. For all cadres of workers, we have sought quantitative information and provide statistical indicators on average debt burden, payment delays, hours of work, distance travelled in the context of Covid-19 duty.

Sampling Our total sample size is 201 healthcare workers which includes 95 ASHA workers, 77 Anganwadi workers and 29 ANMs. Our sample of healthcare workers has been drawn to reflect regional representation, COVID infection rates, social and economic indicators. These include Genreal (23%), OBC( 39.3%), SC (16.4%) ST (4%) and others (10.9%)

0 8 Our sample of women workers are a representative sample with a mix of urban and rural, household head status (women headed households), SC/ST and Upper castes, districts that are Covid Red zones (to understand the work burden and other anxieties) and states with tribal and hard-to reach populations.

Limitations

Initially, we had aimed to conduct 250 interviews between the months of October and December across 10 states. However, due to several ground level challenges, we were able to conduct 201 interviews.There have been several challenges which have impacted the number of interviews conducted by our investigators. Health workers have not responded due to work burden or have not consented to interviews due to fear of state reprisal. Madhya Pradesh and Bihar went into bye-elections between October and December, causing a delay and number of responses. In some cases, husbands of ASHA workers intervened between investigator and respondent either by restricting their conversations or talking on their behalf.Across states, ASHA and Anganwadi workers have been involved in protests and demonstrations demanding better work and wage conditions. During protests, particularly in the state of Maharashtra, respondents have been unavailable for interviews.Despite the above limitations, our study presents coherent narratives and data points that elucidate the experiences of frontline health workers engaged in pandemic duty. These study findings, due to small sample sizes are indicative of situations on ground and experiences of healthcare workers.

0 9 Burden of Work

Burden of Work Among ASHA workers

As a community health worker, an ASHA worker caters to a population of 1000-1500 people in her area. Apart from the routine tasks of prenatal and antenatal check- ups, immunization, communicable and non-communicable disease surveillance,ASHA workers across states have been at the frontline of Covid-19 duty performing crucial Covid activities. These include:

Door-to Door Surveys: Across states ASHA workers have been conducting syndromic surveys, checking for Covid-19 symptoms among community members. In the states of Haryana, Karnataka and Delhi, ASHA workers have been assigned 10-12 rounds of Covid-19 related surveys at the time of conducting the interviews. In each round they have had to collect descriptive information of medical histories, occupation, demographic details of several categories of individuals. Each round of survey for a designated population cover had to be completed within a week.

Besides Covid related surveys, they have had to perform other surveys as well. In Haryana, ASHA workers had to distribute o AYUSH ministry recommended Ayurvedic ingredients to every household.

In Uttar Pradesh, ASHA workers were assigned additional surveys during Diwali and Chatt Puja as a large number of people returned to their villages to attend these festivals. ASHA workers in Karnataka were asked to get all pregnant women tested for Covid-19, without which they were not allowed inside healthcare facilities.

Contact Tracing: Across all states, ASHA workers have been involved in contract tracing of suspected Covid-19 patients through detailed listing of travel and contact histories. Particularly in the context of the migrant returnees and travellers from abroad, in early months of the lockdown, they were involved in listing details of travel, contact persons of every person entering the village.

Policing Quarantine Centres: In the early months of the pandemic, Covid-19 positive patients were either sent to hospitals or institutional quarantine centres, which was the task of ASHA workers.

1 0 Due to the large waves of migrant returnees returning to their homes, ASHAs had to be on-call for 24 hours in a day, meet and collect details on any outsider coming into their aiea. Particularly in rural areas, due to lack of police personnel, ASHA workers have been policing quarantine centres. In the later months of the pandemic, ASHAs were also responsible for ensuring that families followed home isolation protocols.

First-point-of-contact for community members: As a first point of contact for the community, ASHA workers' roles stretched beyond usual work hours, being on call round-the-clock, to attend to any health complications in the community.

"We have to arrange for an ambulance to get people tested,especially when medical staff at the PHC or the police officials were unresponsive" said Kavita Devi, ASHA worker in Khagaria district of Bihar.

Working in Containment Zones: As a Covid-19 control measure, areas with a high number of Covid-19 cases are notified as containment zones with restricted entry. In many states, ASHA workers risked their lives working inside containment zones without adequate facilities. In Delhi, ASHA workers were tasked to identify each Covid-19 patient in a containment zone and asked to survey 50 houses surrounding each Covid-19 case for the purpose of contact tracing. In containment zones, ASHAs also had to set up testing camps, collect and maintain information on all persons tested.

ASHA workers,on an average, have had to visit 25-50 households each day. ASHA facilitators, visited anywhere between 50-100 households on any given day.

As a result of the increased pandemic duties, ASHA workers have, on an average, had to work in the field for 8- 14 hours everyday including weekends.

1 1 Non-Covid Work During the Pandemic

ASHA workers across states were roped in to conduct many non-pandemic and non-healthcare related duties.

Election Duty in Madhya Pradesh and Bihar : ASHA workers were placed on election duty for sanitization and thermal screening protocol in polling booths.

Even during the lockdown they had been arranging vaccination sessions and pregnant women checkup in anganwadi centres, following all social distancing protocols. As community members are scared to go for vaccination and pregnant women checkup, they were also engaged in door-to-door counselling.

Non-Covid Work During the Pandemic

ASHA workers across states were roped in to conduct many non-pandemic and non-healthcare related duties.

Election Duty in Madhya Pradesh and Bihar : ASHA workers were placed on election duty for sanitization and thermal screening protocol in polling booths.

Madhya Pradesh: As part of Dastak Abhiyaan, to address Under 5 malnutrition related mortality rates, ASHA workers have been conducting block level PDS surveys to enumerate families that are in need of ration kits.

Telangana: ASHA workers were roped in for flood relief duty in the state in the month of October. ASHA workers were also assigned survey duty for updation of a newly launched land management website called Dharani.

1.Footnates Dastak Abhiyaan is an Madhya Pradesh state government initiative to address child malnutrition through active screening of children with severe anaemia, malnutrition, pneumonia and iodine deficiency. http://www.nhmmp.gov.in/WebContent/CHN/Dastak_guidelinenew/Concept_Note_on_Dastak_Abhiyaan_MP_20_04_17.pdf accessed on 1.01.2021 Telangana Government has initiated a digital land records management website for which ASHA workers have been collecting data. https://dharani.telangana.gov.in/homePage?lang=en accessed on 1.01.2021 Integrated Child Development Scheme is the world’s largest early childhood care and development program introduced on 2nd October, 1975. http://icds- wcd.nic.in/icds.aspx ccessed on 1.01.2021. https://www.mygov.in/campaigns/poshanabhiyaan/ https://www.mygov.in/campaigns/poshanabhiyaan/

1 2 Apart from surveillance and quarantine work, ASHA workers were involved in distributing essential medicines, sticking Covid-19 seals on households and public health messaging.

While a bulk of non-covid work was halted across several states during the lockdown months, they have resumed since the lockdown lifted. ASHA workers while continuing with ongoing Covid duties are also conducting polio drives, antenatal care visits, disease surveillance for tuberculosis, leprosy, cataract and cancer among other duties.

Burden of work among Anganwadi Workers

Anganwadis workers (AWWs), as Integrated Child Development Scheme (ICDS) scheme workers are mainly responsible for keeping track of mother and child health indicators, running Anganwadi centers which provide cooked meals and pre-school training to young children. Anganwadis also organize ‘Poshan Maah’ in the month of September as part of POSHAN Abhiyaan- a central government programme to encourage community participation in addressing malnutrition.

During the pandemic, cooked meal services have halted due to the closure of most Anganwadis. AWWs have been distributing dry rations to individual households through door-to-door visits or by inviting family members over to the centre during these times.

As part of the ICDS scheme which is responsible for nutritional care of communities, AWWs’ efforts at distributing rations to households during the pandemic are crucial in addressing the food security issues among poorer households in the country. As the latest data from Phase I of National Family and Health Survey-5 survey report shows, there has been a 7.5% increase in the prevalence of anaemia among women in the age group between 15-49 years and 15% increase in anaemia in children aged between six months and five years.

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1 3 A W W s h a v e r e c a l i b r a t e d t h e i r d u t i e s t o e n s u r e t h a t p r i m a r y w o m e n a n d c h i l d c a r e r e m a i n s o n t r a c k d u r i n g t h e p a n d e m i c . T o a v o i d t h e r i s k o f i n f e c t i o n , t h e y h a v e b e e n c a r r y i n g o u t h o m e v i s i t s t o w e i g h c h i l d r e n a n d o r g a n i z i n g p r e n a t a l c h e c k - u p s f o r s m a l l b a t c h e s o f p r e g n a n t w o m e n a t m e d i c a l s u b c e n t e r s . W e v i s i t t h e m ( w o m e n o f t h e v i l l a g e ) a n d a s k t h e m i f t h e i r p e r i o d i s o n t i m e , r e g i s t e r t h e i r n a m e s a n d a s k t h e m t o c o m e t o t h e s u b - c e n t r e s o t h a t t h e A N M c a n g u i d e t h e m . S o m e t i m e s i f d u e t o c o v i d t h e y a r e u n a b l e t o c o m e t h e n w e r e s c h e d u l e b u t w e m a k e s u r e t h a t t h e y g e t t h e v a c c i n e . ’ s a i d P u r n i m a M o h a n , A n g a n w a d i w o r k e r a t C h a r a i d e o d i s t r i c t , A s s a m .

A l o n g w i t h t h e i r c o r e a c t i v i t i e s i n t r a c k i n g c o m m u n i t y h e a l t h a n d n u t r i t i o n , A n g a n w a d i w o r k e r s d u t i e s o v e r l a p p e d w i t h t h o s e o f A S H A w o r k e r s i n m a n y s t a t e s w h i c h i n c l u d e c o n d u c t i n g s y n d r o m i c s u r v e y s , e n s u r i n g h o m e q u a r a n t i n e a n d p u b l i c h e a l t h m e s s a g i n g .

Burden of work Among Auxiliary Nurse Midwives (ANMs)

Each ANM supervises 6-8 villages as part of her duty. During Covid-19 ANMs were conducting field visits for contact tracing and syndromic surveys and conducting Covid-19 tests as well as work in containment zones.

In states like Madhya Pradesh and Karnataka, ANMs were part of emergency teams on call for spot-checking of every patient in case of any complications. In some instances, ANMs have also had to work as laboratory technicians.

‘We have been conducting tests ourselves since the lab technicians were on strike’, said Sunita Kumari, ANM worker in Khagaria district of Bihar.

ANMs interviewed across states mentioned that their work hours have increased to 10-11 hours per day during the pandemic. Apart from 10 to 11 hours of work in the field, they also have to work on digital updation of data.

‘Before Covid-19 we would have 6-8 hours of work. During Covid-19 times,we have worked throughout the night to update details online. Sometimes I would also have to ask my friends or my husband to help me out with the digital work’, said Kumari Diksha, an ANM worker at Gadchiroli district in Maharashtra.

As medical subcenters were functional across most states, routine non- covid related activities such as vaccination and Antenatal Care duties were undertaken by the ANMs. They have provided these services at the doorsteps of the community as well.

1 4 Honorarium Payments During The Pandemic

In most states, except Andhra Pradesh, Kerala, Karnataka, Haryana, West Bengal and Sikkim, ASHA workers do not get a fixed monthly payment.

ASHA workers are entitled to Rs 2,000 a month, doubled in October 2018 from Rs 1,000 by the central government ( and in some cases like Assam topped by by Rs 1000 extra from the state government) for a set of 8 tasks. ASHA workers also earn incentives for 66 tasks, ranging from Rs one for every oral rehydration solution (ORS) packet distributed to Rs 300 for each institutional birth and antenatal care and so on.

On an average, ASHA workers earn anywhere between 8000 and 10000.As many routine activities such as immunization, pregnant women check ups, Home based Newborn Care (HBNCs), were suspended during the lockdown period, ASHA workers across states saw a drop in their incomes sometimes by half.

86% of ASHA workers we interviewed reported a drop in incomes from March onwards.

In Telangana, their incomes dropped anywhere between Rs 3000-5000 and in Haryana and Bihar by Rs 1000-1500.

Covid-19 Incentive

In April 2020, Ministry of Health and Family Welfare (MOHFW) announced Covid-19 incentive of Rs. 1000 incentive for all ASHA workers for the period of January to June. Later extended till September. States like Delhi, Maharashtra and Karnataka announced additional incentives.- Rs 500 for 50 houses surveyed in Delhi and a one time extra incentive of Rs 3000 in Karnataka.

However, ASHA workers in across states have experienced delays in receiving this incentive- in some districts they have not received the incentives for all months. In Khagaria district, Bihar and Bidisha district of Madhya Pradesh ASHA workers had not received Covid-19 incentive until November when the interviews were conducted.

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1 5 3 1 % o f A S H A w o r k e r s h a d n o t r e c e i v e d t h e C o v i d - 1 9 i n c e n t i v e a t t h e t i m e o f t h e s u r v e y

I n H a r y a n a , A S H A w o r k e r s n o t e d t h a t t h e y h a d r e c e i v e d t h e i r C o v i d - 1 9 i n c e n t i v e u n t i l J u l y . I n J i n d d i s t r i c t o f H a r y a n a , A S H A w o r k e r s o r g a n i z e d p r o t e s t s d e m a n d i n g P P E a n d i n c r e a s e i n p a y m e n t s , a s a r e s u l t o f w h i c h A S H A w o r k e r s w e r e d e n i e d t h e i r A u g u s t i n c e n t i v e .

P a y m e n t D e l a y s

R e g u l a r h o n o r a r i u m p a y m e n t s f o r A S H A w o r k e r s a r e a l m o s t a l w a y s d e l a y e d . T h e y h a v e t o m a i n t a i n m e t i c u l o u s r e c o r d s o f t h e t a s k s t h a t t h e y p e r f o r m t o c l a i m t h e i r p a y m e n t s . F o r i n s t a n c e , i n B i h a r , A S H A w o r k e r s r e c e i v e p a y m e n t s a f t e r t h e y s u b m i t v o u c h e r s f o r t h e t a s k s t h e y h a v e c o m p l e t e d . B u t o f t e n , s u p e r v i s o r s h o l d b a c k t h e v o u c h e r s t h e m s e l v e s .

‘ W e h a v e t o s u b m i t a f u l l d a a w a p r a m a a n p a t r a ( v o u c h e r s f o r p r o o f o f w o r k ) e v e r y m o n t h b u t w e d o n ' t g e t t o f i l l i t e v e r y m o n t h . I f y o u a s k t h e g o v e r n m e n t , i t w i l l t e l l y o u t h a t a l l d a t a r e g a r d i n g t h e s e d o c u m e n t s a r e u p d a t e d d i g i t a l l y . B u t t h e g r o u n d r e a l i t i e s a r e a b s o l u t e l y o p p o s i t e o f t h a t ’ , s a i d o n e A S H A w o r k e r i n B i h a r ’ s K h a g a r i a d i s t r i c t .

T h e i n c e n t i v e b a s e d p a y m e n t s , a p a r t f r o m c a u s i n g v a r i a t i o n s i n p a y a m o n g A S H A w o r k e r s , i s a l s o r e l i a n t o n t h e c o m p l e t i o n o f t a s k , s u b m i s s i o n o f d o c u m e n t a r y p r o o f a n d s u p e r v i s o r y a p p r o v a l s - a l l o f w h i c h w e r e a f f e c t e d d u r i n g t h e p a n d e m i c c a u s i n g a c o n s i d e r a b l e d r o p i n t h e i r i n c o m e s .

1 6 5 1 % o f A S H A w o r k e r s r e p o r t e d a d e l a y i n h o n o r a r i u m p a y m e n t s . 1 2 % o f t h e m h a v e n o t b e e n p a i d f o r 3 m o n t h s , w h i l e 5 % r e p o r t e d d e l a y s o f 6 m o n t h s .

A t t h e t i m e o f t h i s s t u d y , A S H A r e s p o n d e n t s n o t e d e x p e r i e n c i n g 2 t o 6 m o n t h s ’ d e l a y i n r e c e i v i n g p a y m e n t s . M o r e o v e r , s e v e r a l t a s k s t h e y u n d e r t a k e r e m a i n u n p a i d f o r . I n A s s a m a n d B i h a r A S H A w o r k e r s r e p o r t e d n o t b e i n g p a i d f o r H o m e B a s e d N a t a l C a r e v i s i t s a n d i n M a d h y a P r a d e s h , t h e y h a v e n o t r e c e i v e d i n c e n t i v e s f o r t u b e r c u l o s i s w o r k f o r o v e r 8 m o n t h s .

B i h a r a n d J h a r k h a n d , A S H A w o r k e r s r e p o r t e d t h a t b l o c k - l e v e l a u t h o r i t i e s o f t e n r e f u s e t o s i g n o f f f o r p a y m e n t s w i t h o u t b r i b e s . I n K a r n a t a k a , d e t a i l s o f c o m p l e t e d t a s k s h a v e t o b e u p l o a d e d b y n u r s e s a n d A N M s a t t h e P r i m a r y H e a l t h C e n t r e o n t h e M o t h e r C h i l d T r a c k i n g S y s t e m ( M C T S ) , f a i l i n g w h i c h A S H A w o r k e r s l o s e o u t o n i n c e n t i v e s .

“ F i r s t , o u r i n c e n t i v e s a r e n o t p a i d i n t h e s a m e m o n t h a s t h e p o r t a l i s u p d a t e d . W h e n w e a s k t h e m , t h e y a c c u s e u s o f n o t u p d a t i n g p r o p e r l y . T h a t ’ s n o t e v e n o u r w o r k . T h e n u r s e s a r e s u p p o s e d t o d o i t w h o a r e n e g l i g e n t a n d w e e n d u p n o t g e t t i n g p a i d f o r o u r w o r k " , G e e t h a , A S H A w o r k e r a t B e l l a r y d i s t r i c t o f K a r n a t a k a .

N e e l a D e v i , a n A S H A w o r k e r i n M u l u g u d i s t r i c t o f T e l e n g e n a , n o t e s t h e r e a r e d i s c r e p a n c i e s i n p a y m e n t s r e c e i v e d b y w o r k e r s i n t r i b a l a n d n o n - t r i b a l a r e a s i n t h e s t a t e . I n t r i b a l a r e a s A S H A w o r k e r s h a v e r e c e i v e d p a y m e n t s i n t h e r a n g e o f R s 2 0 0 0 - 3 0 0 0 , w h e r e a s i n o t h e r n o n - t r i b a l d i s t r i c t s w o r k e r s w e r e p a i d i n t h e r a n g e o f R s . 7 2 0 0 - 7 5 0 0 . O n c o m p l a i n i n g t o t h e D i s t r i c t M e d i c a l H e a l t h O f f i c e r , o f f i c i a l s r e s p o n d e d t h a t d u e t o l o w e r n u m b e r s o f C o v i d c a s e s , A S H A s w o r k i n g i n t r i b a l a r e a s h a v e b e e n p a i d l e s s .

F o o t n o t e s h t t p s : / / d i g i t a l i n d i a . g o v . i n / c o n t e n t / m o t h e r - c h i l d - t r a c k i n g - s y s t e m - m c t s a c c e s s e d o n 1 . 0 1 . 2 0 2 0 h t t p s : / / p i b . g o v . i n / P r e s s R e l e a s e P a g e . a s p x ? P R I D = 1 6 0 2 3 9 4 a c c e s s e d o n 1 . 0 1 . 2 0 2 0

1 7 H o n o r a r i u m s o f A n g a n w a d i W o r k e r s

A n g a n w a d i s r e c e i v e f i x e d h o n o r a r i u m s f o r t h e i r d u t i e s . A s p e r g o v e r n m e n t d a t a , t h e p r e s e n t r a t e o f h o n o r a r i a p a i d t o t h e A n g a n w a d i w o r k e r s ( A W W ) & A n g a n w a d i H e l p e r s ( A W H ) R s . 4 5 0 0 / - a n d R s . 2 , 2 5 0 / - p e r m o n t h r e s p e c t i v e l y .

O v e r a n d a b o v e c e n t r a l g o v t h o n o r a r i u m s , e v e r y s t a t e w i t h a f e w e x c e p t i o n s p a y a d d i t i o n a l h o n o r a r i u m s t o A W W s a n d A W H s . T h e t o t a l i n c o m e o f A n g a n w a d i w o r k e r s r a n g e b e t w e e n R s . 4 5 0 0 - 7 5 0 0 p e r m o n t h a c r o s s s t a t e s .

H o w e v e r , A n g a n w a d i w o r k e r s r e p o r t e d d e l a y s r a n g i n g f r o m 2 - 4 m o n t h s , s o m e e v e n u p t o 1 0 m o n t h s , i n r e c e i v i n g t h e i r r e g u l a r h o n o r a r i u m s .

6 0 % A n g a n w a d i W o r k e r s r e p o r t e d d e l a y s i n h o n o r a r i u m s . 2 0 % h a v e n o t b e e n p a i d f o r 2 m o n t h s .

A b o v e a l l , A n g a n w a d i w o r k e r s a r e n o t e n t i t l e d t o t h e e x t r a R s 1 0 0 0 a m o n t h C o v i d - 1 9 i n c e n t i v e t h a t w a s a n n o u n c e d f o r A S H A w o r k e r s f o r d o i n g C o v i d d u t i e s .

S a l a r y a n d B e n e f i t s o f A N M s

A s g o v e r n m e n t h e a l t h c a r e s t a f f , A N M s r e c e i v e f i x e d p a y m e n t s t h a t r a n g e b e t w e e n a b a s i c s a l a r y o f R s . 2 2 5 0 0 - 3 1 0 0 0 a c r o s s s t a t e s . I n K a r n a t a k a , h o w e v e r , A N M s r e c e i v e a s l o w a s R s . 1 0 0 0 0 a s m o n t h l y s a l a r y . I n C h i k k a b a l l a p u r d i s t r i c t , K a r n a t a k a t h e s a l a r i e s h a v e b e e n s l a s h e d t o R s . 7 0 0 0 p e r m o n t h a s A N M s h a d p r o t e s t e d d e m a n d i n g w o r k a n d w a g e b e n e f i t s .

1 8 T h e r e a r e d e l a y s i n p a y m e n t s a s i n t h e c a s e o f o t h e r f r o n t l i n e h e a l t h c a r e w o r k e r s . T h e y r e c e i v e t h e i r p a y m e n t s i n b u l k , p a r t i c u l a r l y d u r i n g f e s t i v a l s s u c h a s D u r g a P u j a a n d D i w a l i w h e n p a y m e n t c y c l e s a r e r e n e w e d .

T h e o t h e r n o t a b l e o b s e r v a t i o n w a s t h e d i f f e r e n c e b e t w e e n p e r m a n e n t A N M s a n d t h o s e h i r e d o n c o n t r a c t , w h o e a r n l e s s t h a n t h e f o r m e r c a t e g o r y . I n M a d h y a P r a d e s h A N M s w o r k i n g o n c o n t r a c t r e p o r t e d t h a t t h e y w e r e p a i d a m o n t h l y s a l a r y o f R s . 1 5 0 0 0 , w h i l e t h e p e r m a n e n t s t a f f w e r e p a i d a n a v e r a g e o f R s . 2 2 7 0 0 a n d d i d n o t r e c e i v e o t h e r s o c i a l s e c u r i t y b e n e f i t s l i k e m a t e r n i t y l e a v e e t c .

Debt Burden Of Healthcare Workers

S e v e r e d e l a y s a n d l o s s o f h o n o r a r i u m s a n d i n c e n t i v e s , c o u p l e d w i t h o u t o f p o c k e t e x p e n d i t u r e s h a v e r e s u l t e d i n n e w c y c l e s o f d e b t a m o n g a l l t h r e e c a t e g o r i e s o f h e a l t h c a r e w o r k e r s .

T h e C o v i d - 1 9 i n c e n t i v e f o r A S H A w o r k e r s , e v e n i n s t a t e s w h e r e t h e y h a v e b e e n r e g u l a r l y d i s b u r s e d , h a s n o t b e e n s u f f i c i e n t t o m a k e u p f o r t h e l o s s o f i n c e n t i v e s . R s 1 0 0 0 w h i c h t r a n s l a t e s t o R s 3 3 a d a y h a v e b e e n d e s c r i b e d b y a l l A S H A w o r k e r s a s a ‘ j o k e ’

“ G o v e r n m e n t p a y s R s 3 0 , 0 0 0 t o R s 4 0 , 0 0 0 e v e r y m o n t h t o s t a f f w h o s e j o b i t i s t o s i t u n d e r t h e f a n a n d w a i t f o r o u r r e p o r t s . W e r i s k o u r l i v e s a n d w h a t d o w e g e t ? R s 3 3 a d a y . W o u l d y o u r i s k y o u r l i f e f o r t h i s m o n e y ? , ” s a i d a n a n g r y C h a m p a b e n R a t h w a , a n A S H A w o r k i n g i n S o n a g a d h i n B h a v n a g a r d i s t r i c t o f G u j a r a t .

E v e n i n p r e - p a n d e m i c t i m e s , A S H A w o r k e r s w h o c o m e f r o m v e r y p o o r f a m i l i e s a n d m a r g i n a l i s e d c o m m u n i t i e s , s u c h a s D a l i t s a n d A d i v a s i s , f o u n d i t d i f f i c u l t t o r u n t h e i r h o u s e h o l d s o n t h e i r h o n o r a r i u m s . L o c k d o w n a n d p a n d e m i c r e l a t e d j o b l o s s e s o f o t h e r m e m b e r s o f t h e i r f a m i l i e s h a s l e d t o f u r t h e r e c o n o m i c v u l n e r a b i l i t y .

1 9 ‘ O n a n a v e r a g e , A S H A w o r k e r s r e p o r t e d d e b t i n c u r r e d d u r i n g t h e p a n d e m i c r a n g i n g f r o m R s . 1 0 , 0 0 0 t o 4 0 , 0 0 0 . I n s o m e i n s t a n c e s , A S H A w o r k e r s r e p o r t e d a d e b t b u r d e n o f o v e r 1 l a k h r u p e e s .

‘ I h a d t o p a w n m y M a n g a l s u t r a d u r i n g t h e p a n d e m i c b e c a u s e w e n e e d e d R s . 5 0 0 0 . W e a r e d r o w n i n g i n d e b t ! W e h a d t o t a k e o u t b o t h o u r c h i l d r e n , s t u d y i n g i n 8 t h a n d 9 t h g r a d e f r o m s c h o o l . W e h a d a l o t o f d r e a m s , b u t n o w w e h a v e n o t h i n g l e f t ’ , r u e d P r a m i l a K a r m a , a n A S H A w o r k e r i n K h a r g o n e d i s t r i c t o f M a d h y a P r a d e s h .

O f t e n , A S H A w o r k e r s t a k e u p e x t r a j o b s t o m e e t t h e i r e x p e n d i t u r e n e e d s l e a d i n g t o a s e v e r e d i s r u p t i o n i n t h e i r w o r k - l i f e b a l a n c e a n d d i s t u r b a n c e i n t h e i r h o u s e h o l d d y n a m i c s .

" I h a d t o w o r k i n f a r m s t o e a r n m o r e . I h a d t o c o n v i n c e t h e m e d i c a l s t a f f t o p a y m e f o r w h a t e v e r t i m e I w o r k o n t h e f a r m b e c a u s e I a m g e n e r a l l y l a t e b e c a u s e o f t h i s f o r s u r v e y w o r k . I w o u l d w o r k o n f a r m s t i l l 1 2 n o o n f o l l o w i n g w h i c h I w o u l d c o m p l e t e t h e h e a l t h s u r v e y a n d r e p o r t t o m y s u p e r v i s o r a n d b e d o n e b y 1 . T h e n I h a d t o g o h o m e a n d f i n i s h m y h o u s e h o l d w o r k l i k e c o o k i n g a n d c l e a n i n g . I w o u l d r e p o r t f o r a d d i t i o n a l A S H A d u t i e s b y 2 P M a n d c o m e b a c k o n l y a f t e r 6 P M . H o w e l s e c a n I m a n a g e ? ” - - - - S u d a r s h a n a , a n A S H A w o r k e r i n S a t a r a d i s t r i c t o f M a h a r a s h t r a . ’

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2 0 I n m a n y s t a t e s , s u c h a s T e l a n g a n a , A S H A w o r k e r s r e p o r t e d t a k i n g l o a n s f r o m m i c r o f i n a n c e g r o u p s a n d p r i v a t e m o n e y l e n d e r s . M a n y A S H A w o r k e r s , l i k e I s h r a t J a h a n i n D e l h i a n d M i n a r a B e g u m i n A s s a m r e p o r t e d s e l l i n g p e r s o n a l b e l o n g i n g s , j e w e l l e r y , h o u s e h o l d a s s e t s s u c h a s m o b i l e p h o n e s a n d w a s h i n g m a c h i n e s t o m e e t t h e i r f a m i l y e x p e n s e s .

A n g a n w a d i w o r k e r s , w h i l e r e c e i v i n g f i x e d m o n t h l y h o n o r a r i u m , r e p o r t e d i n c u r r i n g d e b t s d u r i n g t h e p a n d e m i c d u e t o s e v e r e d e l a y s i n p a y m e n t s . I n U t t a r P r a d e s h , A W W s r e c e i v e d b u l k p a y m e n t s f o r t h e p r e v i o u s m o n t h s j u s t b e f o r e t h e D i w a l i f e s t i v a l i n N o v e m b e r .

E d u c a t i o n a l a n d m e d i c a l e x p e n s e s f o r m t h e b u l k o f t h e d e b t b u r d e n . D u e t o i n c r e a s i n g d e b t b u r d e n , A W W s a v o i d s e e k i n g m e d i c a l h e l p f o r t h e i r o w n p h y s i c a l a i l m e n t s .

I n m a n y s t a t e s , A W W s m e n t i o n e d t h a t t h e y h a d t o b o r r o w m o n e y o n i n t e r e s t t o p a y r e n t f o r t h e A n g a n w a d i c e n t e r s w h i c h d o n o t o p e r a t e o u t o f g o v e r n m e n t b u i l d i n g s . 2 4 . 3 % A W C s o u t o f 1 3 . 6 3 l a k h o p e r a t i o n a l A W C s ( r u r a l a n d u r b a n ) a r e c u r r e n t l y o p e r a t i n g i n r e n t e d b u i l d i n g s . R e n t p a y m e n t s f r o m t h e g o v e r n m e n t a r e o f t e n d e l a y e d b y t h e g o v e r n m e n t , s o m e t i m e s u p t o 6 m o n t h s , a n d e v e n w h e n t h e y a r e r e i m b u r s e d t o t h e A W W s , t h e i n t e r e s t a m o u n t i s n o t .

S o m e A W W s o r g a n i z e t h e m s e l v e s a n d j o i n s e l f - h e l p g r o u p s w h i c h l e n d m o n e y t o s t r u g g l i n g w o r k e r s . I n A s s a m , s e l f - h e l p g r o u p s h a v e b e e n p i v o t a l i n p r o v i d i n g c r e d i t t o A W W s

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F o o t n o t e h t t p s : / / p i b . g o v . i n / P r e s s R e l e a s e P a g e . a s p x ? P R I D = 1 5 4 1 5 5 8 a c c e s s e d o n 1 . 0 1 . 2 0 2 0

2 1 A S H A , A N M a n d A n g a n w a d i w o r k e r s h a v e t o t a k e u p o n o u t o f p o c k e t e x p e n d i t u r e w h i l e o n d u t y . D u r i n g t h e p a n d e m i c , h e a l t h w o r k e r s r e p o r t e d s p e n d i n g u p t o R s . 1 5 0 0 o n p r o t e c t i v e e q u i p m e n t , f o o d a n d w a t e r , s t a t i o n e r y e t c . A N M s a c r o s s s t a t e s a l s o i n c u r e x p e n s e s o u t o f t h e i r o w n p o c k e t s f o r a c t i v i t i e s s u c h a s p a y i n g r e n t f o r t h e s u b c e n t r e s t h e y o p e r a t e f r o m a s g o v e r n m e n t b u i l d i n g s h a v e n o t b e e n a l l o t t e d .

M o r e o v e r , m o s t w o r k e r s r e p o r t e d t h a t t h e y n e i t h e r r e c e i v e a n y t r a v e l a l l o w a n c e , n o r a n y g o v e r n m e n t v e h i c l e f o r c o n d u c t i n g f i e l d v i s i t s . D u r i n g t h e l o c k d o w n , t h e l a c k o f t r a n s p o r t c r e a t e d f u r t h e r i s s u e s .

Medical Apathy and Deaths On Duty

S e v e r a l A S H A w o r k e r s i n B i h a r , M a d h y a P r a d e s h , D e l h i , A s s a m a n d J h a r k h a n d d i e d , e i t h e r d u e t o C o v i d - 1 9 i n f e c t i o n o r m i s h a p s s u c h a s r o a d a c c i d e n t s a n d e v e n e x h a u s t i o n w h i l e d o i n g t h e i r h e a l t h c a r e d u t i e s .

I n B i h a r , a t l e a s t a d o z e n d i e d w h i l e c o n d u c t i n g C o v i d - 1 9 r e l a t e d s u r v e y s i n M o t i h a r i , S u r a j g a r h a , M u z a f f a r p u r d i s t r i c t s a c c o r d i n g t o t h e A S H A w o r k e r s ’ s u n i o n l e a d e r S h a s h i Y a d a v .

‘ S o m e A S H A w o r k e r s f e l l s i c k b u t t h e y w e r e n ’ t t e s t e d . D o c t o r s i n t h e P H C w o u l d n o t e v e n t o u c h t h e m . S i c k A S H A w o r k e r s w e r e t h r o w n o u t o f t h e P H C . O n e o f t h e m d i e d o u t s i d e a p r i v a t e c l i n i c . ’

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2 2 T h e M i n i s t r y o f H e a l t h a n d F a m i l y W e l f a r e , a n n o u n c e d R s . 5 0 l a k h i n s u r a n c e c o v e r a g e u n d e r t h e ‘ P r a d h a n M a n t r i G a r i b K a l y a n P a c k a g e I n s u r a n c e S c h e m e f o r H e a l t h W o r k e r s F i g h t i n g C O V I D - 1 9 ’ f o r a l l p u b l i c a n d p r i v a t e h e a l t h c a r e p r o v i d e r s a n d f r o n t l i n e h e a l t h w o r k e r s i n t h e e v e n t o f l o s s o f l i f e d u e t o C o v i d - 1 9 i n f e c t i o n o r w h i l e d o i n g C o v i d - 1 9 r e l a t e d d u t y . S o m e s t a t e s , s u c h a s B i h a r , a n n o u n c e d e x t r a i n s u r a n c e p a y o u t s o n t o p o f t h e c e n t r a l g o v e r n m e n t i n s u r a n c e f o r a l l f a m i l i e s o f d e c e a s e d C o v i d - 1 9 p a t i e n t s .

I n m a n y s t a t e s , i n s u r a n c e p a y o u t s t o A S H A w o r k e r s ’ f a m i l i e s h a v e b e e n h a r d t o c o m e b y . I n B i h a r , n o n e o f t h e A S H A w o r k e r s ' f a m i l i e s r e c e i v e d i n s u r a n c e m o n e y b e c a u s e o f b u r e a u c r a t i c l o o p h o l e s . T h e G o v e r n m e n t o f B i h a r m a n d a t e d a n F I R t o b e l o d g e d a n d a p o s t m o r t e m r e p o r t t o c l a i m i n s u r a n c e p a y o u t . W h a t k i n d o f a n F I R w o u l d b e l o d g e d i f a n A S H A w o r k e r d i e d d u e t o e x h a u s t i o n w h i l e s u r v e y i n g o n f o o t f o r h o u r s ? ” , a s k s S h a s h i Y a d a v . S o m a n y s u c h d e a t h s w e n t u n r e c o r d e d .

S i m i l a r n a r r a t i v e s w e r e r e p o r t e d f r o m A s s a m , w h e r e a n A S H A w o r k e r ’ s f a m i l y i n B a r p e t a d i s t r i c t w a s d e n i e d i n s u r a n c e o n t h e p r e t e x t t h a t t h e w o r k e r h a d p a s s e d a w a y w h i l e o n C o v i d - 1 9 d u t y a n d n o t d u e t o t h e C o v i d - 1 9 i n f e c t i o n .

I n D e l h i , a l m o s t 1 5 0 A S H A w o r k e r s t e s t e d p o s i t i v e f o r C o v i d - 1 9 a l o n g w i t h t h e i r e n t i r e f a m i l i e s w h o h a v e n o t r e c e i v e d a n y m e d i c a l s u p p o r t .

‘ A S H A w o r k e r s m a y r e c e i v e a m b u l a n c e s e r v i c e b u t t h e r e i s n o s u p p o r t f o r i n f e c t e d f a m i l y m e m b e r s . T h e r e a r e n o s a f e s p a c e s f o r A S H A s l i k e h o t e l s f o r d o c t o r s . A S H A g o t o i s o l a t i o n c e n t r e s , g e t p a t i e n t s t e s t e d a n d t h e n g o b a c k t o t h e i r o w n h o m e s ” , s a i d K a v i t a Y a d a v , D e l h i A S H A W o r k e r s ’ U n i o n l e a d e r

F o o t n o t e s h t t p s : / / w w w . m o h f w . g o v . i n / p d f / F A Q P r a d h a n M a n t r i G a r i b K a l y a n P a c k a g e I n s u r a n c e S c h e m e f o r H e a l t h W o r k e r s F i g h t i n g C O V I D 1 9 . p d f a c c e s s e d o n 1 . 0 1 . 2 0 2 0 h t t p s : / / w w w . b u s i n e s s - s t a n d a r d . c o m / a r t i c l e / p t i - s t o r i e s / n i t i s h - a n n o u n c e s - r s - 4 - l a k h - e x - g r a t i a - f o r - 1 3 - c o v i d - 1 9 - d e a t h s - i n - b i h a r - 1 2 0 0 5 2 4 0 1 0 7 3 _ 1 . h t m l a c c e s s e d o n 1 . 0 1 . 2 0 2 0

2 3 Culture of Bribes

A S H A a n d A n g a n w a d i w o r k e r s r e p o r t e d a p r e v a l e n t c u l t u r e o f b r i b e r y t o a c c e s s t h e i r o w n h o n o r a r i u m s w h i c h s i g n i f i c a n t l y i m p a c t s t h e i r p a y m e n t s , p a r t i c u l a r l y i n t h e s t a t e s o f B i h a r a n d J h a r k h a n d .

‘ B l o c k l e v e l o f f i c e r s a s k u s t o p a y R s 1 0 0 a s b r i b e f r o m o u r i n c e n t i v e s . T h e c u m u l a t i v e c u t c a n g o u p t o I N R 1 0 0 0 . W h a t a r e o u r h o n o r a r i u m s a n y w a y t h a t w e c a n p a y t h a t b r i b e ? S o w e a s k t h e m t o k e e p o u r i n c e n t i v e m o n e y . E v e r y t h i n g r u n s o n t h r e a t s ” , s a i d A S H A w o r k e r f r o m D e o g a r h d i s t r i c t o f J h a r k h a n d .

M a n y s u p e r v i s o r s t a k e b r i b e f r o m A n g a n w a d i w o r k e r s b e c a u s e t h e y d o n o t k n o w h o w t o d i g i t a l l y u p l o a d d a t a . C u r r e n t l y , t h e y d e m a n d 2 k i l o s p u r e D e s i g h e e a n d 1 q u i n t a l w h e a t t o u p l o a d M o t h e r a n d C h i l d T r a c k i n g d a t a o n d i g i t a l a p p s e v e r y m o n t h ’ , s a i d H a z r a N a j m i , A W W l e a d e r a t B h o p a l d i s t r i c t o f M a d h y a P r a d e s h .

Training For Healthcare workers

A S H A w o r k e r s r e c e i v e p r e l i m i n a r y t r a i n i n g e i t h e r f r o m g o v e r n m e n t m e d i c a l s t a f f o r f r o m N G O s .

H o w e v e r , f o r c a r r y i n g o u t t h e i r C o v i d - 1 9 d u t i e s , A S H A w o r k e r s r e c e i v e d s h o r t d u r a t i o n s o f o n l i n e a s w e l l a s i n - p e r s o n t r a i n i n g o n s o c i a l d i s t a n c i n g p r o t o c o l s , p u b l i c h e a l t h m e s s a g i n g a s w e l l a s p e r s u a d i n g p e o p l e t o g o t o q u a r a n t i n e c e n t r e s . I n t h e e a r l y m o n t h s o f t h e p a n d e m i c , A S H A w o r k e r s i n m a n y s t a t e s m e n t i o n e d t h a t t h e y w e r e d e p u t e d t o f i e l d d u t i e s w i t h o u t a n y t r a i n i n g w h a t s o e v e r . T h e y p i c k e d u p i n f o r m a t i o n o n s a f e t y p r o t o c o l s f r o m s o u r c e s s u c h a s r a d i o a n d t e l e v i s i o n .

A W W s r e c e i v e t r a i n i n g f o r t h e i r r e g u l a r d u t i e s a s w e l l a s p e r i o d i c r e f r e s h e r t r a i n i n g c o u r s e s a t t h e p u b l i c h e a l t h c e n t r e . F o r c a r r y i n g o u t C o v i d - 1 9 d u t i e s , A W W s r e p o r t e d t o h a v e r e c e i v e d n o o n - s i t e p h y s i c a l t r a i n i n g . ‘ W e h a v e l e a r n t a s m u c h a s w e c o u l d f r o m t h e t e l e v i s i o n ’ , s a i d M o n j u m o n i G o g o i o f J o r h a t d i s t r i c t , A s s a m .

2 4 A N M s r e c e i v e d p r e l i m i n a r y t r a i n i n g b o t h o n l i n e a n d o n - s i t e f o r C o v i d - 1 9 d u t i e s . D u e t o t h e i r c l o s e i n t e r a c t i o n w i t h t h e m e d i c a l s t a f f a t P H C a n d d i s p e n s a r y , A N M s a r e a b l e t o a c c e s s m e d i c a l s u p p l i e s , p a r t i c u l a r l y p r o t e c t i v e e q u i p m e n t a n d s a n i t i z e r s . A N M r e s p o n d e n t s m e n t i o n e d t h a t t h e i r s u b c e n t e r s a r e w e l l - e q u i p p e d w i t h r e q u i s i t e m e d i c a l a n d d i a g n o s t i c s u p p l i e s .

Facilities For Healthcare Workers

E v e n b e f o r e t h e p a n d e m i c , A S H A w o r k e r s h a d v e r y l i t t l e f a c i l i t i e s p r o v i d e d b y t h e g o v e r n m e n t b o t h w i t h i n t h e h e a l t h c a r e f a c i l i t i e s a n d a s w e l l a s o n t h e f i e l d d u t i e s . A s h e a l t h c a r e w o r k e r s w h o h a v e t o a t t e n d t o p r e g n a n t w o m e n a n d o t h e r p a t i e n t s a n d a c c o m p a n y t h e m t o h o s p i t a l s , t h e y a r e r a r e l y p r o v i d e d w i t h w a i t i n g a n d r e s t r o o m s w i t h i n t h e h o s p i t a l s - e s p e c i a l l y b e c a u s e t h e y a r e n o t d e s i g n a t e d a s k i n o f t h e p a t i e n t s . T h e y a r e m a d e t o w a i t o u t s i d e t h e h o s p i t a l s a n d P H C s . D u r i n g f i e l d d u t y A S H A s f a c e c o n s i d e r a b l e d i f f i c u l t y i n a c c e s s i n g p u b l i c t o i l e t s . M a n y A S H A w o r k e r s r e p o r t e d l a c k o f a c c e s s t o w a t e r a n d l o n g g a p s b e t w e e n m e a l s d u r i n g f i e l d v i s i t s , w h i c h h a s a n a d v e r s e i m p a c t o n t h e i r p h y s i c a l h e a l t h .

“ S o m e t i m e s w e n e e d t o s t a y a t t h e h o s p i t a l t h e e n t i r e n i g h t b u t w e c a n ' t u s e t h e r e s t r o o m . W e d o n ' t e v e n g e t d r i n k i n g w a t e r e v e n o n v e r y h o t d a y s ” , s a i d P r a m i l a , a n A S H A w o r k e r i n K h a r g o n e d i s t r i c t o f M a d h y a P r a d e s h .

D u r i n g t h e p a n d e m i c , m o s t A S H A w o r k e r s r e p o r t e d l a c k o f s e p a r a t e i s o l a t i o n f a c i l i t i e s a f t e r d i s c h a r g i n g t h e i r r i s k y d u t i e s w h i c h i n v o l v e d c o m i n g i n d i r e c t c o n t a c t w i t h C o v i d - 1 9 p a t i e n t s .

“ T h e G o v e r n m e n t c o u l d d e s i g n a t e a s m a l l r o o m o n t h e o u t s k i r t s o f t h e v i l l a g e f o r u s t o i s o l a t e a n d s a n i t i s e o u r s e l v e s . A f t e r r i s k i n g o u r l i f e a l l d a y , w e a r e c o n c e r n e d a b o u t g o i n g b a c k t o o u r h o m e s a n d i n f e c t i n g o u r f a m i l i e s ” , s a i d L a k s h m i , a n A S H A f a c i l i t a t o r f r o m B h i n d d i s t r i c t i n M a d h y a P r a d e s h .

D u r i n g t h e p a n d e m i c , h o w e v e r , A N M s h a v e f a c e d d i f f i c u l t y i n c o n d u c t i n g f i e l d v i s i t s d u e t o l a c k o f g o v e r n m e n t v e h i c l e s . A s A N M s a r e r e s p o n s i b l e f o r s u p e r v i s i o n o f 8 - 1 0 v i l l a g e s , t h e y f a c e d g r e a t d i f f i c u l t y i n c o v e r i n g t h e e n t i r e a r e a , p a r t i c u l a r l y d u r i n g t h e l o c k d o w n .

2 5 S i m i l a r l y , A W W s h a v e f a c e d d i f f i c u l t y i n a c c e s s i n g t o i l e t s d u r i n g t h e i r w o r k h o u r s , w h i c h l e a d s t h e m t o u s e f a c i l i t i e s i n n e a r b y s c h o o l s . M i n i s t r y o f W o m e n a n d C h i l d D e v e l o p m e n t , d a t a s h o w s t h a t A n g a n w a d i c e n t r e s i n m o s t s t a t e s h a v e n o t o i l e t f a c i l i t i e s . 9 3 % o f A W C s i n A r u n a c h a l P r a d e s h a n d 6 8 % i n O d i s h a d i d n o t h a v e t o i l e t f a c i l i t i e s .

Physical Health of Healthcare Workers

A l l t h r e e c a d r e s - A S H A , A N M a n d A n g a n w a d i w o r k e r s - r e p o r t e d h i g h l e v e l s o f p h y s i c a l a n d m e n t a l e x h a u s t i o n d u r i n g t h e p a n d e m i c .

A S H A a n d A n g a n w a d i w o r k e r s h a v e h a d t o c o n d u c t t h e i r h o u s e h o l d v i s i t s a n d s u r v e y s l a r g e l y o n f o o t . O n a n a v e r a g e A S H A w o r k e r s h a v e h a d t o w a l k 3 - 6 k m s p e r d a y i n r u r a l a r e a s a n d 1 0 k i l o m e t e r s o r m o r e i n u r b a n a r e a s .

I n t h e a b s e n c e o f g o v e r n m e n t t r a n s p o r t a t i o n , b o t h b e f o r e a n d d u r i n g t h e p a n d e m i c , A S H A w o r k e r s h a v e f a c e d s e v e r e l e v e l s o f p h y s i c a l e x h a u s t i o n d u r i n g t h e s u m m e r m o n t h s f r o m A p r i l t o J u n e ( i n s o m e s t a t e s b e y o n d J u n e a s w e l l ) . T h i s w a s p a r t i c u l a r l y d i f f i c u l t i n u r b a n a r e a s w h e r e t h e y h a v e h a d t o c o v e r l a r g e d i s t a n c e s .

F o o t n o t e h t t p s : / / r a j y a s a b h a . n i c . i n / r s n e w / C o m m i t t e e _ s i t e / C o m m i t t e e _ F i l e / R e p o r t F i l e / 1 6 / 1 2 3 / 3 1 4 _ 2 0 2 0 _ 3 _ 1 4 . p d f a c c e s s e d o n 1 . 0 1 . 2 0 2 0

2 6 A S H A w o r k e r s a l s o r e p o r t e d t h a t t h e y a r e n o t a l l o w e d t o t r a v e l i n t h e a m b u l a n c e w h e n t h e y a c c o m p a n y p a t i e n t s t o h o s p i t a l s . T h e y w e r e a s k e d b y t h e h e a l t h c a r e s t a f f t o e i t h e r w a l k o r m a k e t h e i r a r r a n g e m e n t s f o r t r a n s p o r t .

A S H A w o r k e r s r e p o r t e d w e i g h t l o s s , k n e e a n d j o i n t p a i n s e s p e c i a l l y d u r i n g t h e p a n d e m i c . A S H A w o r k e r s l i k e K a v i t a D e v i o f P a t n a i n B i h a r h a d t o u n d e r g o s u r g e r y f o r h e r k n e e p a i n . R e k h a M a l v i , a n A S H A w o r k e r i n B h o p a l d i s t r i c t o f M a d h y a P r a d e s h r e p o r t e d t a k i n g p a i n k i l l e r s t o n u m b h e r p h y s i c a l p a i n a n d e x h a u s t i o n d u r i n g t h e p a n d e m i c .

“ W e a r e n o t a b l e t o e a t p r o p e r l y , n o t a b l e t o s l e e p p r o p e r l y . W e a r e m a d e t o r u n a r o u n d f o r r e p o r t s , f o r t e s t s a n d o t h e r A S H A t a s k s . T h i s h a s b e e n i m p a c t i n g o u r h e a l t h ” , s a i d G e e t h a , a n A S H A U n i o n l e a d e r i n B e l l a r y d i s t r i c t o f K a r n a t a k a .

A n g a n w a d i w o r k e r s , a s p a r t o f t h e i r C o v i d - 1 9 d u t i e s , w e r e r e q u i r e d t o d e l i v e r r a t i o n s i n d i v i d u a l l y t o h o u s e h o l d s a t t h e i r d o o r s t e p s d u e t o t h e c l o s u r e o f A n g a n w a d i c e n t r e s . A l m o s t a l l s t a t e g o v e r n m e n t s h a d d e c l a r e d h o u s e h o l d d e l i v e r y o f r a t i o n s . A W W s h a v e h a d t o h a u l h e a v y r a t i o n k i t s o n t h e i r s h o u l d e r s .

‘ W e h a d t o c o l l e c t 5 0 k g s r i c e a n d 1 5 k g s m a t a r ’ m e n t i o n e d J a y a , A n g a n w a d i w o r k e r i n M a r i a n i d i s t r i c t o f A s s a m .

I n K h a m m a m d i s t r i c t o f T e l a n g a n a , A n g a n w a d i w o r k e r s m e n t i o n e d t h a t t h e y h a d t o c o l l e c t f o o d f r o m t h e r a t i o n s h o p s f o r c o m m u n i t y d i s t r i b u t i o n .

‘ W e h a d t o c a r r y 1 0 0 k g f o r 2 - 3 k m , s o m e t i m e s e v e n w a l k u p t o 1 0 k m s f o r r a t i o n d i s t r i b u t i o n ’ s a i d , K o t e s h w a r i , a n A W W i n K h a m m a m d i s t r i c t , T e l a n g a n a . A W W s n o t e d t h a t t r a n s p o r t i n g h e a v y l o a d s o f r a t i o n f o r d i s t r i b u t i o n a l s o r e s u l t e d i n a d d e d t r a n s p o r t e x p e n d i t u r e f o r t h e m .

I n A s s a m , A W W s r e p o r t e d t h a t t h e y w e r e t h r e a t e n e d w i t h d i s m i s s a l , w h e n t h e y q u e s t i o n e d t h e o v e r b u r d e n i n g a n d i n c r e a s e d s c o p e o f t h e i r w o r k . A W W s a l s o n o t e d i n c i d e n c e o f w e i g h t l o s s , l o w e r e d h a e m o g l o b i n l e v e l s a n d p h y s i c a l e x h a u s t i o n , s o m e t i m e s e v e n t r a g i c c o n s e q u e n c e s - s u c h a s S h a g u f t a K h a n , a n A n g a n w a d i w o r k e r i n B h o p a l d i s t r i c t o f M a d h y a P r a d e s h w h o s u f f e r e d a m i s c a r r i a g e .

2 7 ‘ T h e m i n i s t r y w e w o r k u n d e r i s c a l l e d t h e M i n i s t r y o f W o m e n a n d C h i l d D e v e l o p m e n t . W e a r e a l s o w o m e n a n d w e h a v e c h i l d r e n , b u t d o e s t h e g o v e r n m e n t c a r e a b o u t u s ? I h a d t o d o C o v i d d u t y w h i l e I w a s t w o m o n t h s ’ p r e g n a n t w h i l e d o i n g r o z a ( f a s t i n g d u r i n g t h e h o l y m o n t h o f R a m z a n ) d u r i n g p e a k s u m m e r . I l o s t m y b a b y a n d m y h e a l t h h a s d e t e r i o r a t e d ’ s a i d S h a g u f t a , w h o h a s b e e n m o u r n i n g t h e l o s s o f h e r b a b y .

A N M s r e p o r t e d s i m i l a r p h y s i c a l a i l m e n t s i n j o i n t s , k n e e s a n d e x h a u s t i o n . F r o n t l i n e h e a l t h w o r k e r s h a v e r e p o r t e d h e i g h t e n e d l e v e l s o f m e n t a l s t r e s s a r i s i n g f r o m p a n d e m i c d u t y . F e a r o f i n f e c t i o n , o n f i e l d p h y s i c a l a t t a c k s a n d d i s c r i m i n a t i o n a g a i n s t f r o n t l i n e h e a l t h w o r k e r s h a v e i m p a c t e d m e n t a l h e a l t h o u t c o m e s o f a l l t h r e e c a d r e s o f w o r k e r s . D e b t b u r d e n h a s a d d e d a n o t h e r l a y e r o f s t r e s s f o r h e a l t h c a r e w o r k e r s .

Mental Health of Healthcare Workers

A s w o r k h o u r s h a v e i n c r e a s e d w i t h m o s t w o r k e r s r e m a i n i n g o n - c a l l f o r a l m o s t 2 4 h o u r s , w h i c h h a s h a d a n a d v e r s e i m p a c t o n p e r s o n a l r e l a t i o n s h i p s a n d h o u s e h o l d d y n a m i c s , s o m e t i m e s l e a d i n g t o d o m e s t i c a b u s e t o o .

“ F a m i l y d i s c o r d i s r a m p a n t a m o n g t h e f a m i l i e s o f t h e A S H A w o r k e r s . B e c a u s e w e d o n o t h a v e f i x e d w o r k h o u r s a n d w e g e t s u c h l i t t l e m o n e y . T h i s t r i g g e r s f i g h t s w i t h i n t h e f a m i l y , b e t w e e n d a u g h t e r - i n - l a w a n d m o t h e r - i n - l a w , b e t w e e n h u s b a n d a n d w i f e , w i t h c h i l d r e n ” , T u t u m o n i L a h o n , A S H A w o r k e r i n K a m r u p m e t r o d i s t r i c t .

T h e b u r d e n o f C o v i d w o r k h a s e x a c e r b a t e d f e a r o f i n f e c t i o n f o r h e a l t h c a r e w o r k e r s . A S H A a n d A W W s r e p o r t e d s e v e r e m e n t a l s t r e s s , p a r t i c u l a r l y i n t h e i n i t i a l m o n t h s o f t h e p a n d e m i c .

2 8

‘ W e f e e l s o m u c h f e a r . E v e n w e h a v e c h i l d r e n a n d h a v e t o , w e t a k e c a r e o f t h e w o r l d , b u t w h o c a r e s f o r u s ? I t e l l m y c h i l d r e n n o t t o c o m e c l o s e t o m e . ’ m e n t i o n e d S h i k s h a , A S H A w o r k e r M a y u r V i h a r d i s t r i c t , N e w D e l h i .

C o l l e c t i o n a n d r e p o r t i n g o f d a t a w i t h s h o r t t u r n a r o u n d c y c l e s h a s a l s o c a u s e d p h y s i c a l a n d m e n t a l e x e r t i o n f o r h e a l t h c a r e w o r k e r s . L o s s o f s l e e p d u e t o r e p o r t i n g o b l i g a t i o n s a l s o a d d s t o s e v e r e h e a l t h o u t c o m e s . ‘ S o m e t i m e s I h a v e t o s t a y u p l a t e a f t e r d o i n g h o u s e h o l d c h o r e s t o f i n i s h w r i t i n g r e p o r t s ’ m e n t i o n e d J a y a A n g a n w a d i w o r k e r i n M a r i a n i d i s t r i c t , A s s a m .

D u r i n g t h e p a n d e m i c , s e v e r a l w o r k e r s h a v e h a d t o d i s c o n t i n u e t h e i r c h i l d r e n ’ s e d u c a t i o n , u n a b l e t o a f f o r d a n d r o i d p h o n e s f o r d i g i t a l c l a s s e s c a u s i n g s e v e r e a n x i e t y f o r w o r k e r s .

T o d e a l w i t h m e n t a l a n d p h y s i c a l s t r e s s a c c r u i n g t o p a n d e m i c c o n d i t i o n s , m a n y w o r k e r s n o t e d t h a t w h i l e t h e y d o n o t h a v e o f f i c i a l g r i e v a n c e r e d r e s s a l m e c h a n i s m s , t h e y h a v e f o u n d s o m e s u p p o r t a m o n g f e l l o w w o r k e r s a n d s o m e h i g h e r o f f i c i a l s . I n m a n y d i s t r i c t s , B l o c k M e d i c a l O f f i c e r s , h e a l t h s t a f f a t t h e P r i m a r y H e a l t h C e n t r e h a v e d i r e c t l y a d d r e s s e d i n s t a n c e s o f v e r b a l a n d p h y s i c a l a b u s e a g a i n s t A S H A w o r k e r s . I n D e l h i , t h e D e l h i A S H A w o r k e r s ’ U n i o n ( D A W A ) h a s b e e n a t t h e f o r e f r o n t o f d e m a n d i n g s t r i c t a c t i o n a g a i n s t c o m m u n i t y m e m b e r s w h o h a v e a s s a u l t e d A S H A s o n d u t y .

F a m i l y m e m b e r s h a v e b e e n i m p o r t a n t s o u r c e s o f s u p p o r t f o r a l l c a d r e s o f w o r k e r s .

2 9 Protective Equipment

P r o t e c t i v e p r o t e c t i v e e q u i p m e n t ( P P E s ) , e v e n b a s i c o n e s , s u c h a s m a s k s , g l o v e s a n d s a n i t i s e r s w e r e n o t p r o v i d e d b y t h e g o v e r n m e n t t o A S H A a n d A n g a n w a d i w o r k e r s , d e s p i t e t h e f a c t t h a t t h e y h a v e b e e n a t t h e f r o n t l i n e s a n d i n d i r e c t c o n t a c t w i t h t h e c o m m u n i t y a n d p o t e n t i a l r i s k o f C o v i d - 1 9 i n f e c t i o n . A S H A w o r k e r s r e p o r t e d u s i n g t h e i r d u p a t t a ( c l o t h s c a r v e s ) t o p r o t e c t t h e m s e l v e s f r o m i n f e c t i o n s w h i l e o n f i e l d d u t y .

A c r o s s s t a t e s , a n d i n d e e d a t t h e n a t i o n a l l e v e l , d e m a n d f o r a d e q u a t e s a f e t y g e a r h a v e b e e n t h e c e n t r a l d e m a n d s o f f r o n t l i n e h e a l t h c a r e w o r k e r s .

I n m o s t s t a t e s s u c h a s B i h a r , D e l h i , U P , K a r n a t a k a h e a l t h c a r e w o r k e r s r e p o r t e d t h a t t h e y r e c e i v e d P P E s o n l y t w i c e s i n c e t h e p a n d e m i c o u t b r e a k . W h e r e v e r h e a l t h c a r e w o r k e r s d i d r e c e i v e m a s k s , t h e y w e r e o f m e d i o c r e q u a l i t y .

A S H A w o r k e r s c o m p l a i n e d t h a t w h i l e o t h e r h e a l t h c a r e s t a f f l i k e d o c t o r s , n u r s e s , l a b o r a t o r y t e c h n i c i a n s r e c e i v e d f u l l P P E g e a r o n l y a f t e r t h e y c a m e i n c o n t a c t w i t h i n f e c t e d p a t i e n t s , t h e y h a v e h a d t o c o n t e n d w i t h i m p r o v i s e d s o l u t i o n s s u c h a s h a n d k e r c h i e f s , s a r e e e n d s o r d u p a t t a s .

I n m a n y s t a t e s , A S H A a n d A n g a n w a d i w o r k e r s h a v e b e e n s t i t c h i n g m a s k s f o r p e r s o n a l u s e a s w e l l a s f o r d i s t r i b u t i o n a m o n g c o m m u n i t y m e m b e r s a n d e v e n t o p a t i e n t s w h o v i s i t e d t h e s u b c e n t e r s . I n s o m e c a s e s , A S H A w o r k e r s d i s t r i b u t e d m a s k s t h e y r e c e i v e d t o A n g a n w a d i w o r k e r s .

3 0 I n s o m e d i s t r i c t s A S H A a n d A n g a n w a d i w o r k e r s r e c e i v e d m a s k s , s a n i t i z e r s a n d t h e r m o m e t e r s f r o m N G O s s u c h a s t h e P r e m j i f o u n d a t i o n o r p r i v a t e c o m p a n i e s s u c h a s B a t a i n N a s h i k ( M a h a r a s h t r a ) . I n o t h e r s t a t e s , s e l f - h e l p g r o u p s w e r e i n s t r u m e n t a l i n s t i t c h i n g a n d d i s t r i b u t i n g m a s k s f o r h e a l t h c a r e w o r k e r s .

A N M s , h o w e v e r , h a v e h a d b e t t e r a c c e s s t o P P E s a s t h e y a r e a t t a c h e d t o t h e P H C s a n d m e d i c a l d i s p e n s a r i e s t h r o u g h t h e h e a l t h s u b c e n t e r s . I n M a d h y a P r a d e s h , A N M s r e p o r t e d r e c e i v i n g P P E k i t s , g l o v e s , m a s k s a n d s a n i t i z e r 1 5 t i m e s . T h e y a l s o r e c e i v e d p u l s e o x i m e t e r s a n d t h e r m o m e t e r s . i t w a s n o t u n i f o r m h o w e v e r .

I n G a d c h i r o l i d i s t r i c t o f M a h a r a s h t r a , A N M s r e p o r t e d n o t r e c e i v i n g a n y P P E k i t s . S i m i l a r l y , i n B i h a r , A N M s r e p o r t e d t h a t t h e y w e r e d e n i e d p r o t e c t i v e e q u i p m e n t b y t h e g o v e r n m e n t . I n K h a g a r i a d i s t r i c t , A N M s w e r e a s k e d t o b u y s a f e t y k i t s f o r t h e i r p e r s o n a l u s e .

T h e y g a v e u s P P E s o n l y i n t h e e a r l y d a y s . A f t e r t h a t t h e y a s k e d t o p u r c h a s e o n o u r o w n . W e w e r e a s k e d t o w r i t e t o t h e C h i e f S e c r e t a r y o f H e a l t h M i n i s t r y a b o u t o u r g r i e v a n c e s a b o u t l a c k o f P P E s b u t g o v e r n m e n t d i d n o t h i n g ’ , s a i d S u n i t a K u m a r i , a n A N M a t K h a g a r i a d i s t r i c t .

F r o n t l i n e h e a l t h c a r e w o r k e r s h a v e r e p o r t e d i n s t a n c e s o f d i s c r i m i n a t i o n a n d v i o l e n c e b o t h f r o m w i t h i n t h e c o m m u n i t y a n d o t h e r h e a l t h c a r e s t a f f a n d g o v e r n m e n t o f f i c i a l s i n c l u d i n g t h e p o l i c e d u r i n g t h e p a n d e m i c . I n m a n y s t a t e s , A S H A w o r k e r s w e s u r v e y e d , m e n t i o n e d t h a t t h e y h a v e b e e n s u s p e c t e d a n d v i l i f i e d f o r b e i n g c a r r i e r s o f t h e C o v i d - 1 9 i n f e c t i o n t h e m s e l v e s . T u t u m o n i L a h o n , A S H A u n i o n l e a d e r i n A s s a m s a i d t h a t t h e y w e r e c a l l e d “ C o r o n a W a l l a h s ” w i t h i n t h e c o m m u n i t y . T h e y h a v e n o t b e e n a l l o w e d i n s i d e h o m e s d e s p i t e t h e i r y e a r s o f w o r k w i t h i n t h e c o m m u n i t i e s t h e y s e r v e

3 1 Discrimination and Violence On Healthcare Workers

I n s o m e s t a t e s , A S H A w o r k e r s r e p o r t e d b e i n g d e n i e d e n t r y i n t o P H C s a n d d i s p e n s a r i e s b y m e d i c a l s t a f f . I n m a n y i n s t a n c e s , A S H A , A N M a n d A W W w o r k e r s h a v e h a d t o s e e k a s s i s t a n c e f r o m v i l l a g e s a r p a n c h , p a n c h a y a t o f f i c i a l s a n d e v e n t h e p o l i c e t o p u t p a t i e n t s i n t o q u a r a n t i n e , c o n v i n c e t h e m t o g e t C o v i d - 1 9 t e s t s d o n e .

I n D e l h i , A S H A w o r k e r s r e p o r t e d t h a t C o v i d - 1 9 s u r v e y s b e c a m e e v e n m o r e c h a l l e n g i n g a s m a n y f a m i l i e s f e a r e d t h a t t h e i n f o r m a t i o n w a s c o l l e c t e d f o r t h e N a t i o n a l C i t i z e n s h i p R e g i s t e r , w h i c h w a s t h e r e a s o n f o r a l l I n d i a p r o t e s t s d u r i n g l a t e 2 0 1 9 a n d e a r l y 2 0 2 0 . S e v e r a l A S H A w o r k e r s w e r e a t t a c k e d i n S o u t h a n d N o r t h - e a s t D e l h i , r e p o r t e d a n A S H A w o r k e r i n K a r a w a l N a g a r o f N o r t h - e a s t D e l h i P a n d e m i c s u r v e y s a n d d u t i e s w e r e i n t e r r u p t e d d u e t o i n t e r - g r o u p t e n s i o n s w i t h i n c o m m u n i t i e s .

‘ A m o n g t h e M u s l i m c o m m u n i t i e s , t h e r e w a s g r a v e s u s p i c i o n t h a t a n A S H A w o r k e r b e l o n g i n g t o t h e B o d o c o m m u n i t y w a s c o n s p i r i n g t h e m w h i c h l e a d t o s o m e t e n s i o n f o r t h e A S H A w o r k e r s ’ , s a i d a n A S H A l e a d e r i n A s s a m .

A S H A w o r k e r s , i n s e v e r a l s t a t e s , f a c e d p h y s i c a l t h r e a t s a n d g r i e v o u s v i o l e n t a t t a c k s a g a i n s t t h e m . T h e H a r y a n a A S H A w o r k e r s U n i o n c o l l e c t e d c a s e s o f 2 0 A S H A w o r k e r s , i n 2 2 d i s t r i c t s , w h o w e r e p h y s i c a l l y a t t a c k e d b y t h e c o m m u n i t y . T h e u n i o n l e a d e r s m e n t i o n e d t h a t t h e y r e c e i v e d l i t t l e h e l p f r o m t h e p o l i c e a n d a u t h o r i t i e s , s o m e t i m e s e v e n g r e a t e r v i l i f i c a t i o n b y t h e m .

I n U t t a r P r a d e s h A S H A w o r k e r s w e r e c h a s e d a w a y b y c o m m u n i t y m e m b e r s w i t h t h r e a t s o f v i o l e n c e .

I n T e l a n g a n a , A S H A w o r k e r s w e r e a t t a c k e d w h i l e v i s i t i n g h o u s e h o l d s f o r a n t e n a t a l a n d p r e n a t a l c h e c k u p s . I n K a r n a t a k a , c o m m u n i t y m e m b e r s t h r e w c h i l l i p o w d e r a t A S H A w o r k e r s a n d s o m e w e r e b e a t e n w i t h r o d s .

A S H A l e a d e r s m e n t i o n e d t h a t t h e r e a s o n f o r h o s t i l i t y a m o n g t h e c o m m u n i t y w a s t h e i n a d e q u a t e p u b l i c m e s s a g i n g b y t h e g o v e r n m e n t w h o d i d n o t u n d e r s t a n d t h e n a t u r e o f t h e p a n d e m i c a n d w e r e t h e m s e l v e s v e r y s c a r e d .

3 2 “ I f t h e G o v e r n m e n t h a d d o n e p r o a c t i v e m e s s a g i n g a n d a l l a y e d t h e f e a r s w i t h i n t h e c o m m u n i t y , t h e n m e m b e r s o f t h e p u b l i c w o u l d h a v e b e e n l e s s h o s t i l e t o u s ” , s a i d S u n i t a R a n i , a n A S H A w o r k e r a n d u n i o n l e a d e r i n H a r y a n a .

I n m a n y i n s t a n c e s , t h e h o s t i l i t y w a s a l s o a n e x t e n s i o n o f t h e c a s t e b a s e d d i s c r i m i n a t i o n t h a t A S H A w o r k e r s f r o m D a l i t , A d i v a s i a n d M u s l i m c o m m u n i t i e s f a c e d i n t h e i r e v e r y d a y l i v e s .

“ A t t a c k s o n A S H A s f r o m D a l i t c o m m u n i t i e s i n H a r y a n a a r e h i g h e s p e c i a l l y f r o m t h e l a n d e d c o m m u n i t y s t r o n g m e n a s a m e a n s t o a s s e r t t h e i r c a s t e s u p r e m a c y o n c e a g a i n ” , s a i d S u r e k h a , g e n e r a l s e c r e t a r y o f t h e H a r y a n a A S H A w o r k e r s u n i o n . I n N a r s a m p e t d i s t r i c t o f T e l a n g a n a , o n e A S H A w o r k e r f r o m t h e E r k a l c o m m u n i t y d i e d b y s u i c i d e a f t e r b e i n g s u b j e c t e d t o w o r k p l a c e h a r a s s m e n t b y h e r s u p e r v i s o r y s t a f f . I n K a r n a t a k a , G e e t h a , A S H A u n i o n l e a d e r n o t e d t h a t t h e r e i s w i d e s p r e a d c a s t e b a s e d d i s c r i m i n a t i o n a g a i n s t l o w e r c a s t e a n d D a l i t A S H A w o r k e r s . I n H a r y a n a ’ s K a r n a l d i s t r i c t , A S H A w o r k e r s r e p o r t e d t h a t u p p e r c a s t e c o m m u n i t y m e m b e r s r e f u s e d t o d i v u l g e C o v i d - 1 9 r e l a t e d i n f o r m a t i o n t o D a l i t A S H A w o r k e r s . I n U t t a r P r a d e s h A S H A w o r k e r s w e r e c h a s e d a w a y b y c o m m u n i t y m e m b e r s w i t h t h r e a t s o f v i o l e n c e .

R e k h a S a n y a r , a n A S H A w o r k e r i n M a d h y a P r a d e s h s a i d t h a t u p p e r c a s t e h o u s e h o l d s m a d e h e r s i t o n t h e f l o o r a n d d i d n o t a l l o w h e r t o d r i n k w a t e r o r t e a f r o m h o u s e h o l d u t e n s i l s d u r i n g s u r v e y v i s i t s .

‘ I t p a i n s m e t o s e e t h e m b e h a v e t h a t w a y . W h e n t h e r e a r e c h i l d d e l i v e r i e s , t h e s e s a m e p e r s o n s d r i n k f r o m m y h a n d ’ m e n t i o n e d R e k h a . L a c k o f t r a n s p o r t a t i o n f a c i l i t i e s a n d s e c u r i t y d u r i n g f i e l d d u t y h a s a l s o e x p o s e d A n g a n w a d i w o r k e r s t o p h y s i c a l a s s a u l t a n d s e x u a l v i o l e n c e . I n G a d c h i r o l i d i s t r i c t , M a h a r a s h t r a , a n A W W w a s r a p e d w h e n s h e h a d g o n e t o d i s t r i b u t e f o o d a m o n g w o m e n a n d c h i l d r e n .

H a j i r a B a j i , a n A n g a n w a d i w o r k e r B h o p a l d i s t r i c t M a d h y a P r a d e s h , n o t e d t h a t m e d i a d i s i n f o r m a t i o n l i n k i n g t h e s p r e a d o f C o r o n a v i r u s w i t h M u s l i m c o m m u n i t y a f t e r t h e T a b l i g h i J a m a a t i n c i d e n t a d v e r s e l y i m p a c t e d t h e A n g a n w a d i w o r k e r s w h o w e r e M u s l i m s .

3 3 Coordination Among the Cadres of Healthcare Workers A S H A A N M s a n d A n g a n w a d i w o r k e r s , a s c o m m u n i t y h e a l t h c a r e w o r k e r s o f t e n w o r k i n t a n d e m w i t h i n t h e i r c o m m u n i t i e s . D u r i n g t h e p a n d e m i c , a l l t h r e e c a t e g o r i e s o f w o r k e r s h a v e b e e n r o p e d i n f o r f i e l d d u t i e s i n s t a t e s , m a n y t i m e s b e y o n d t h e r e m i t o f t h e i r d u t i e s .

S i n c e A N M s a r e p e r m a n e n t ( i n s o m e c a s e s c o n t r a c t u a l ) g o v e r n m e n t e m p l o y e e s , t h e y a r e h i g h e r i n t h e b u r e a u c r a t i c l a d d e r a b o v e A S H A a n d A n g a n w a d i w o r k e r s . W h i l e c o o p e r a t i o n b e t w e e n t h e m i s e s s e n t i a l i n c a r r y i n g o u t r e g u l a r d u t i e s , a s s u p e r v i s o r s o f A S H A w o r k e r s , t h e y s h a r e a c o n t e n t i o u s r e l a t i o n s h i p . A S H A w o r k e r s r e p o r t t h a t A N M s t r e a t t h e m r u d e l y a n d e v e n h o l d b a c k a u t h o r i s a t i o n f o r t h e i r i n c e n t i v e p a y m e n t s .

W h i l e A N M s r e p o r t e d t h a t t h e y s h a r e c o r d i a l r e l a t i o n s h i p s w i t h o t h e r m e d i c a l s t a f f , t h e y a r e a l s o t r e a t e d a s m a r g i n a l w i t h i n t h e m e d i c a l s y s t e m . W h e r e a s A N M s a r e t r a i n e d a s s k i l l e d b i r t h a t t e n d a n t s , m o s t d o n o t h a n d l e c o m p l e x o r e v e n s i m p l e b i r t h i n g p r o c e d u r e s a n d r e f e r p a t i e n t s t o d o c t o r s a t t h e P r i m a r y H e a l t h C e n t r e s . I n s o m e c a s e s , A N M s r e p o r t e d a b u s e o f p o w e r b y h i g h e r o f f i c i a l s s o m e t i m e s r e c r u i t i n g t h e m t o d o t h e i r h o u s e h o l d w o r k .

How Data Flows In the Healthcare System

A S H A w o r k e r s r e p o r t t o t h e A S H A f a c i l i t a t o r s , a l s o k n o w n a s S a h a y i k a s . T h e y , i n t u r n , r e p o r t t h e d a t a t o t h e A N M s a n d o t h e r o f f i c i a l s a t t h e P H C . t h e A N M a t t h e s u b c e n t e r . D u r i n g t h e p a n d e m i c , d a t a c o l l e c t e d b y A S H A w o r k e r s d i d n o t r e c e i v e t h e i r a u t h o r s h i p . A p a r t f r o m n o t r e c e i v i n g a n y r e c o g n i t i o n a s h e a l t h c a r e w o r k e r s , c o m p l e t e l y e r a s e s t h e i r w o r k , s a y A S H A w o r k e r s .

“ F o r g e t r e c o g n i t i o n , n o n e o f t h e r e p o r t s w e c o l l e c t a r e s i g n e d b y u s . T h e y a r e f o r w a r d e d a s r e p o r t s o f t h e A u x i l i a r y N u r s e M i d w i v e s ( A N M s ) . T o m o r r o w w h e n a n y a u d i t o f t h i s p a n d e m i c i s c o n d u c t e d , o u r w o r k a n d c o n t r i b u t i o n w i l l r e m a i n i n v i s i b l e ” , s a i d L a k s h m i K a u r a v , a n A S H A w o r k e r i n B h i n d d i s t r i c t o f M a d h y a P r a d e s h .

3 4 A N M s t a k e a d v a n t a g e o f a m b i g u i t y a n d m a k e t h e m w o r k m o r e , s a y A S H A w o r k e r s . I n m a n y s t a t e s l i k e H a r y a n a , P u n j a b , D e l h i , K a r n a t a k a e t c , m o s t o f t h e d a t a r e p o r t i n g t a s k s h a v e m o v e d o n l i n e . B u t A S H A w o r k e r s s a y t h a t t h e g o v e r n m e n t n e i t h e r g a v e t h e m m o b i l e p h o n e s n o r i n t e r n e t p a c k a g e s t o m a k e t h e t r a n s i t i o n . H e a l t h c a r e w o r k e r s i n t h e s e s t a t e s w i t h b a s i c m o b i l e p h o n e s h a d t o s p e n d o u t o f t h e i r p o c k e t s t o b u y a n d r o i d p h o n e s t o a l l o w t h e m t o r e p o r t d a t a w h i l e t h o s e w i t h b e t t e r p h o n e s h a d t o j u g g l e w i t h t h e i r c h i l d r e n ’ s o n l i n e s t u d i e s t o f i n d t i m e t o d o t h e r e p o r t i n g .

A n g a n w a d i w o r k e r s a l s o h a d t o s h i f t t o o n l i n e r e p o r t i n g . T h e y h a v e h a d t o t a k e p i c t u r e s o f p e o p l e i n q u a r a n t i n e a n d s e n d i t t o t h e A N M s a s p a r t o f t h e i r r e p o r t i n g . H o w e v e r , o n l i n e d a t a r e p o r t i n g h a s c r e a t e d a n e w s e t o f p r o b l e m s f o r A W W s .

T h e g o v e r n m e n t h a s g i v e n u s a p h o n e , a s i m c a r d a n d a p o w e r b a n k . B u t t h e y a r e v e r y p o o r q u a l i t y . T h e b a t t e r y o n l y c h a r g e s p a r t i a l l y . I t i s d i f f i c u l t f o r u s t o u p l o a d o u r r e p o r t s a s t h e n e t w o r k i s r e a l l y b a d i n t h e v i l l a g e a r e a s ” , s a i d M e n a M e c h o f D i b r u g a r h d i s t r i c t i n A s s a m .

I n m a n y s t a t e s l i k e U P a n d K a r n a t a k a , A W W s h a v e b e e n d o i n g o n l i n e r e p o r t i n g e v e n b e f o r e t h e p a n d e m i c . A N M s r e p o r t t o L a d y H e a l t h V i s i t o r s , B l o c k M e d i c a l O f f i c e r s a s w e l l a s t h e P r i m a r y H e a l t h C e n t r e s t a f f . B e f o r e t h e p a n d e m i c , A N M s w e r e r e s p o n s i b l e f o r t h e b u l k o f d a t a e n t r y w o r k o n r e p r o d u c t i v e , c h i l d a n d f a m i l y p l a n n i n g i n d i c e s f o r a d e s i g n a t e d a r e a . I n M a d h y a P r a d e s h , t h e y w e r e r e q u i r e d t o u p d a t e p a t i e n t a n d f a m i l y d a t a i n t o t w o a n d r o i d a p p l i c a t i o n s c a l l e d S a r t h a k a n d A n m o l .

A N M s n o t e t h a t t h e d a t a e n t r y w o r k f o r m s t h e b u l k o f t h e i r r e s p o n s i b i l i t i e s . O l d e r A N M s f a c e g r e a t d i f f i c u l t y i n m a n a g e m e n t a n d o n l i n e u p d a t i o n o f d a t a . ‘ I f a c e g r e a t d i f f i c u l t i e s w h e n t h e i n t e r n e t i s n o t w o r k i n g . W e g e t t r a i n i n g e v e r y t i m e w h e n e v e r w e h a v e t o u p l o a d n e w d a t a . G o v e r n m e n t s h o u l d c r e a t e a s p e c i f i c p o s i t i o n o f d a t a o p e r a t o r s b e c a u s e i t i s n o t t h e w o r k f o r A N M ” , s a i d S h y a m a S i n g h , A N M a t S i n g h o u r l i d i s t r i c t o f M a d h y a P r a d e s h .

F o o t n o t e s h t t p s : / / g e o p o r t a l . m p . g o v . i n / S a r t h a k / W e b / L o g i n a c c e s s e d o n 1 . 0 1 . 2 0 2 0 h t t p : / / a n m o l . n h m m p . g o v . i n / H o m e / I n d e x . a s p x a c c e s s e d o n 1 . 0 1 . 2 0 2 0

3 5 Demands

3 6 Demands of Healthcare Workers A S H A W o r k e r s

A S H A w o r k e r s h a v e m a i n l y b e e n d e m a n d i n g f i x e d s a l a r i e s a n d r e g u l a r p a y m e n t s . A S H A w o r k e r s s t a t e t h a t t h e r e s h o u l d b e a f i x e d s a l a r y r a n g i n g b e t w e e n R s 1 0 0 0 0 - 1 8 0 0 0 f o r A S H A w o r k e r s a n d a s a l a r y o f a t l e a s t R s 2 4 0 0 0 f o r A S H A f a c i l i t a t o r s .

A s g o v e r n m e n t e m p l o y e e s t h e y d e m a n d E m p l o y e e S t a t e I n s u r a n c e ( E S I ) , P r o v i d e n t F u n d a n d P e n s i o n b e n e f i t s .

C o v i d - 1 9 i n c e n t i v e f o r A S H A w o r k e r s s h o u l d b e i n c r e a s e d f r o m e x i s t i n g R s 1 0 0 0 p e r m o n t h t o a t l e a s t R s 3 0 0 f o r e a c h d a y o f C o v i d - 1 9 w o r k .

A S H A w o r k e r s d e m a n d t r a v e l a l l o w a n c e a n d w a i t i n g r o o m f a c i l i t i e s i n h o s p i t a l s . I n D e l h i A S H A w o r k e r s d e m a n d t h a t N G O s s h o u l d n o t b e m a d e m e d i a t o r s b e t w e e n t h e m a n d t h e g o v e r n m e n t .

A S H A w o r k e r s a l s o d e m a n d i n c r e a s e d s u p p l y o f d i s p o s a b l e s a f e t y e q u i p m e n t d u r i n g t h e p a n d e m i c .

A S H A w o r k e r s d o n o t r e c e i v e a n y i n s u r a n c e b e n e f i t s . A l t h o u g h A S H A w o r k e r s a r e s u p p o s e d l y c o v e r e d u n d e r t h e P r a d h a n M a n t r i J e e v a n J y o t i B i m a Y o j a n a . A S H A w o r k e r s d e m a n d l i f e a n d m e d i c a l i n s u r a n c e c o v e r . T h e y a l s o d e m a n d t h e C o v i d - 1 9 i n s u r a n c e m o n e y i s d i s b u r s e d f o r d e c e a s e d A S H A w o r k e r s ’ f a m i l i e s .

M o r e o v e r , A S H A w o r k e r s d e m a n d t h a t h a r a s s m e n t w h i l e o n d u t y s h o u l d b e m a d e a p u n i s h a b l e o f f e n c e w h i c h i s a c t e d u p o n s w i f t l y , p a r t i c u l a r l y d u r i n g t h e p a n d e m i c .

O n r e t i r e m e n t , A S H A w o r k e r s r e c e i v e a o n e - t i m e - p a y m e n t o f R s . 2 0 , 0 0 0 . A S H A w o r k e r s d e m a n d r e t i r e m e n t b e n e f i t s a n d p e n s i o n b e t w e e n R s . 2 0 0 0 - 5 0 0 0 a s N a t i o n a l R u r a l H e a l t h M i s s i o n e m p l o y e e s .

F o o t n o t e h t t p s : / / f i n a n c i a l s e r v i c e s . g o v . i n / i n s u r a n c e - d i v i s i o n s / G o v e r n m e n t - S p o n s o r e d - S o c i a l l y - O r i e n t e d - I n s u r a n c e - S c h e m e s / P r a d h a n - M a n t r i - J e e v a n - J y o t i - B i m a - Y o j a n a ( P M J J B Y ) a c c e s s e d o n 1 . 0 1 . 2 0 2 0

3 7 Demands of Anganwadi Workers

A n g a n w a d i W o r k e r s

A n g a n w a d i w o r k e r s d e m a n d h i k e i n t h e i r h o n o r a r i u m s , p r o v i s i o n f o r p r o m o t i o n s a n d r e g u l a r i z a t i o n o f t h e i r e m p l o y m e n t .

A n g a n w a d i w o r k e r s s h o u l d b e c o n s t i t u t e d a s t h i r d g r a d e a n d A n g a n w a d i h e l p e r s a r e f o u r t h g r a d e g o v e r n m e n t e m p l o y e e s r e s p e c t i v e l y a l o n g w i t h e m p l o y e e b e n e f i t s .

A n g a n w a d i w o r k e r s a l s o d e m a n d t h a t t h e u p p e r a g e l i m i t f o r p r o m o t i o n s s h o u l d b e r e m o v e d a n d e x p e r i e n c e d A n g a n w a d i w o r k e r s s h o u l d b e p r o m o t e d a s s u p e r v i s o r s .

T h e i n t r o d u c t i o n o f t h e N a t i o n a l E d u c a t i o n P o l i c y ( N E P ) h a s s o u n d e d w a r n i n g b e l l s a m o n g A n g a n w a d i w o r k e r s . T h e N E P a i m s t o i n t e g r a t e p r e - s c h o o l a n d l o w e r p r i m a r y l e v e l s o f s c h o o l t e a c h i n g . A n g a n w a d i w o r k e r s f e e l t h a t i t c o u l d l e a d t o p e r m a n e n t t e r m i n a t i o n o f t h e i r p o s t s . A W W s h a v e b e e n d e m a n d i n g t h a t t h e i r p o s t s b e r e g u l a r i z e d s o t h a t t h e y a r e n o t r e n d e r e d j o b l e s s a f t e r i m p l e m e n t a t i o n o f t h e N E P .

A n g a n w a d i w o r k e r s a l s o d o n o t r e c e i v e a n y i n s u r a n c e b e n e f i t s a n d t h u s d e m a n d m e d i c a l i n s u r a n c e c o v e r . A s I C D S w o r k e r s t h e y h a v e n o t r e c e i v e d a n y i n f o r m a t i o n r e g a r d i n g t h e i r e l i g i b i l i t y f o r t h e R s . 5 0 l a k h C o v i d - 1 9 i n s u r a n c e s c h e m e . A W W s d e m a n d t h a t t h e y s h o u l d b e i n s u r e d , a l o n g w i t h o t h e r h e a l t h w o r k e r s .

3 8 Demands of Auxiliary Nurse Midwives

A u x i l i a r y N u r s e M i d w i v e s

A N M s i n m o s t s t a t e s s u c h a s M a d h y a P r a d e s h , K a r n a t a k a , U t t a r P r a d e s h a n d B i h a r d e m a n d t h a t a s e p a r a t e p o s t f o r d a t a - e n t r y o p e r a t o r s s h o u l d b e c r e a t e d a t t h e s u b c e n t r e .

A N M s a l s o d e m a n d t h a t t h e d i s c r e p a n c y b e t w e e n s a l a r i e s a n d b e n e f i t s r e c e i v e d b y p e r m a n e n t a n d c o n t r a c t u a l s t a f f w h i c h s h o u l d b e a d d r e s s e d .

A N M s d e m a n d g o v e r n m e n t i n s u r a n c e c o v e r .

3 9 Bibliography

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