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CHWs want lasting social contracts, not endless recognition

CHWs want lasting social contracts, not endless recognition

Women are 70% of health workers across the world, lead and shoulder a significant proportion of the pandemic response, and play key roles in health systems all over the world.  Many of these women, particularly those in lower income countries work as volunteers, in low paid or underpaid roles and without any social protection.

WHO’s Global Strategy on Human Resources for Health: Workforce 2030  has drawn attention to the priority items for global health policy into the future, relevant now more than ever in the post pandemic context. An essential component of HRH is the contribution made by the cadre of Community Health Workers (CHWs) who have stepped up beyond their personal and professional capacity to provide vital healthcare services in their communities. Recently, at the 75th World Health Assembly (WHA),  WHO DG Dr Tedros honored eight volunteer polio workers from Afghanistan who lost their lives, as well as more than one million women CHWs from India, the Accredited Social Health Activist workers (ASHAs). He paid tribute to their service on the frontlines and applauded their courage and commitment, despite the extraordinary challenges and risks faced.

In India, for example, almost two million female CHWs include ASHAs and Anganwadi workers who work in communities and child care centres respectively. The pandemic highlighted the vital role played by these CHWs and the challenges faced such as worker shortages, poor working conditions, and a lack of PPE and resources to effectively carry out their work. Strikes and protests by CHWs, demanding fair pay, social security and decent work were widespread and reported worldwide, but to no effect. Despite being indispensable to the delivery of care during the pandemic, ASHA workers have not been given their due share of support and resources.

Recognizing and applauding their important contribution is long overdue. However, supporting CHWs like the ASHAs requires tangible recognition in the form of adequate payment, decent working conditions, adequate resources, and support for safe and decent work, free from harassment and violence.

Recent (2018) WHO guidelines on health system support for optimizing CHW programmes emphasized the need for a financial package that takes into account job demands such as experience, number of hours worked and training required and undertaken, along with a written agreement focused on roles, responsibilities, working conditions and remuneration.

The newly launched (2022) Global Health and Care Worker Compact Framework, that encompasses the four domains of preventing harm, providing support, inclusivity and safeguarding rights, also covers the critical elements mentioned above for CHWs to function effectively and secure the right to health of our populations. 

For years now, compelling evidence and narratives on the effectiveness of CHW programs in providing healthcare services, and the critical resource needs have been highlighted by various advocacy organizations including Women in Global Health. . 

Post-pandemic, we put forward the following four key recommendations to help build strong and resilient health systems that truly respect CHWs for their contributions.

  1. Respective governments should take ownership of CHWs and give them a designation and due credit as health workers rather than as volunteers. For example, the ASHA Program in India needs to be integrated into the formal health workforce, with all the wage guidelines, social security, and labor laws as applicable in the country. It is strongly recommended that countries make legislative decisions that govern every operational CHW program, ensuring their commitment towards the CHWs, and this regardless of the level or agency implementing it. 
  2. Countries should ratify the ILO conventions C155 (Occupational Health & Safety) and C190 (Eliminate Violence and Harassment at Workplace), and implement measures towards the safety and security of the CHWs, who continue to put their lives at risk when providing healthcare services in their communities. This pertains to labor as well as gender rights. 
  3. Giving CHWs a seat at the table: Leveraging their position in the community, the health system has been rescued at the expense of by CHWs who served communities on the ground during the pandemic. The onus is on global health organizations to include women at the highest level of decision-making.  The latest GH5050 report found less than one percent of women from low-income countries  were represented on the boards of health organizations.
  4. We need to strengthen the mechanisms to identify and respond to the early signs of emerging mental and psychosocial distress faced by CHWs, raise awareness, and normalize seeking care for mental health disorders. 

Volunteer women health workers across the world have been lauded for their sacrifice and commitments, but they have not been rewarded with decent work, equal pay, or gender parity in leadership. It is time for the leaders to wake up to their call.  Health and care workers need a new social contract with fair pay, equal leadership, safe and decent working conditions and workplaces free from violence and harassment! 

Nothing less will do. 

About Deepika Saluja

Cofounder & Chair, Women in Global Health India; Program Manager (Ubuntu Initiative), The George Institute for Global Health.

About Kavita Bhatia

Kavita Bhatia is an independent researcher from India.

About Dr Shubha Nagesh

Shubha Nagesh is a medical doctor and a public health physician based in the Himalayan state of India, Uttarakhand. She is the Chapter development Manager, Asia-Pacific & Middle-East at Women in Global Health. The focus of her work is Gender Transformative Leadership.
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