Workers supporting global public health demand livable wages. future planet

Neeta Kashid has no time to rest. The 44-year-old community health worker’s day is filled with visiting women and children in her village in southwestern Maharashtra, India, helping them in emergencies and providing maternal and newborn support. It also conducts surveys and vaccination campaigns, and acts as the image of the government’s health and sanitation campaigns. Apart from all this, she also has to take care of a small farm because despite being a full-time health worker, she earns less than the minimum wage. “My salary is not enough to survive and I have two children who go to school,” he explains.

Kashid is one of nearly one million accredited social health workers known as Asha, which means ‘hope’ in Hindi. They are part of a Government of India program that acts as a link between rural communities and the public health system. When COVID-19 struck India in 2021, these women rose to prominence for their role in ensuring access to primary care for poor rural patients and won the World Health Organization’s Global Health Leader Award. Health The award has drawn greater attention to the working conditions of community health workers in India as well as around the world.

In recent decades, community care programs have been praised as a cost-effective way to reduce maternal and child mortality, HIV, tuberculosis, and many other diseases. But their profitability is due to the fact that these workers, the majority of whom are women, are underpaid, like Kashid, or receive no salary, because in many countries it is understood that their work is entirely voluntary. Is.

Programs involving these types of workers have been praised as a cost-effective way to reduce maternal and child mortality, HIV or tuberculosis. But their profitability is due to the fact that these workers are poorly paid or do not receive any remuneration.

According to a 2022 report by Women in Global Health, a non-profit organization, there are six million unpaid or underpaid female health workers in the world, although this figure is conservative due to a lack of available data. The research was based on an article published in 2015 in the journal the Lancet which estimated that the unpaid work of community health workers would contribute $1.4 trillion to the global economy, meaning that the unpaid work of health workers, mostly women, was being subsidized by about 2.5% of world GDP at that time . Rupa Dhatt, MD, a physician and executive director of Women in Global Health, asks, “Why don’t we put a price on this specialized labor force and include it in the cost of these programs?” “This is exploitation and must be condemned.”

Indian ASHAs, recognized health social workers, went on strike last year demanding better wages and a labor law that includes health and retirement benefits.

“Community health workers are an anonymous donor, an anonymous benefactor to everyone else,” says Madeleine Ballard, executive director of the nonprofit Community Health Impact Coalition. “In most communities around the world, they are the working poor. In the context of suffering for women and limited access to decent employment opportunities, we are not talking about freely chosen volunteerism, but about wage slavery. I mean you don’t volunteer for your community 37 hours a week,” Ballard explains.

In the context of suffering for women and limited access to decent employment opportunities, we are not talking about freely chosen volunteerism, but about wage slavery. I mean you don’t volunteer 37 hours a week to work for your community.

Madeleine Ballard, Community Health Impact Coalition

“The irony is that many of these programs are funded by international organizations that focus their efforts on women’s empowerment,” says Ballard. “And it is used to give a moral cover to what it really is: programs that cheapen female labor.”

A job too big to pay for

, The Chinese government began programs with rural health workers in the 1930s. So-called “barefoot doctors” became famous in the 1950s and 1960s, and by the 1970s they inspired programs around the world, as the international community came together to make primary health care available to all by the end of the 20th century. The goal of.

The economic crisis of the 1980s set back the development of these programs, but interest in them revived in the new millennium, when the HIV epidemic focused attention on providing services to rural communities across the African continent. Community health workers began to be seen as an effective way to reach marginalized and vulnerable populations to address major global public health problems at the time, such as malaria and tuberculosis. Nowadays, they are going through another promotion cycle after the coronavirus pandemic.

“The amount of money spent on hospital care is extraordinary, but the evidence that investing in hospitals improves people’s health is simply non-existent,” says Henry Perry, a physician and researcher on community workers at the University of Johns Hopkins University (USA). ” “Scans, open heart surgery or kidney transplants are undoubtedly valuable, but they are very expensive compared to the return on investment of community health workers needed to diagnose and treat childhood pneumonia or detect high blood pressure,” he says. “

Scans, open heart surgery or kidney transplants are undoubtedly valuable, but they are very expensive compared to the return on investment of community health workers needed to diagnose and treat childhood pneumonia or detect high blood pressure.

Henry Perry, physician and community activist researcher at Johns Hopkins University

The Accredited Social Health Workers initiative in India has its roots in another 2002 program that was launched in Chhattisgarh, one of the poorest Indian states, and was adopted nationwide in 2005. The goal was to tackle child mortality. “Asha became a necessity for the services provided by the government. The main objective was to reduce the levels of maternal mortality,” explains Sujatha Rao, former secretary of the Ministry of Health and Family Welfare, who attended the launch of the project. And children, whose numbers were unacceptably high.”

When the program was started, ASHA’s responsibilities were limited to awareness raising, counselling, community mobilization and providing some first aid care. Over the years, these responsibilities have grown, as have their schedules: They’ve gone from working a few hours a week to a full-time workload. “In 2009, when I joined, we had five to 10 indicators to focus on,” says Netradeepa Patil, a union leader representing more than 3,000 ASHA workers in Kolhapur. “Now, we have 74 indicators.”

Then Covid came. While they received praise from everyone for their work on the front lines, the ASHAs received hardly any support. Kashid was physically attacked by a villager when he tried to enforce the government’s quarantine rules. Another worker, 43-year-old Usha Jadhav, suffered a heart attack, which doctors said was caused by irregular meal times and high levels of stress arising from work.

For many experts, the struggles of community workers during the pandemic exposed the well-worn lie used to justify their lack of pay: that women, by nature, are meant to serve their neighbors and the community. are motivated, and paying them would reduce their salary. The spiritual benefits of their work. For example, researchers like Kenneth Mace of Oregon State University are finding that far from a state of satisfaction and contentment, community workers in Ethiopia experience more psychological distress throughout the year than other women. This is partly due to the stress of his job and partly due to his uncertain financial situation.

“This is emotional blackmail,” complains Margaret Odera of Nairobi, who is working to form a national union of community workers in Kenya. “People from the United States have come to visit us and told us, ‘You community health workers are doing a great job.’ But when we ask them, ‘So will you pay us?’, they answer: ‘We can’t, because your work is too big to be paid for.’

The health worker details the health data she compiled for her latest report to her supervisors: children dewormed; babies born inside and outside the hospital; malnourished children; pregnant mothers; Community members suffering from non-communicable diseases. And the list doesn’t stop here. Odera remembers her son once saying to her: “Mom, you go to the hospital every day. I think you are a doctor. But at the end of the month, when I ask you to buy something, you say you don’t have money. What is happening?”.

“And you know what?” Odera asks. “I don’t know what to answer.”

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