1. 30 January 2018 Susana Barria, PSI
Decent work for Community Health Workers in South Asia: A Path to Gender Equality and Sustainable Development
30 January 2018
Susana Barria, PSI

2. Community Health Workers in South Asia: Country Comparison
Pakistan
India
Nepal
Sri Lanka
Bangladesh
Workforce
Lady Health Worker (LHW)
Accredited Social Health Activist (ASHA)
Female Community Health Volunteer (FCHV)
Community Health Volunteer (CHV)
Shasthya Shebika (SS)
Year
1994
2005
1988
1976, discontinued
1977
Total workforce
125,000
939,000
53,000
15,000
80,000
Population per CHW
175 households
(1,000-1,200 pp)
200 households
(1,000 people)
125 households
(600 people)
20 households
(100 people)
households
Main tasks
Maternal, neonatal and child health, family planning, health promotion, immunization
Family planning, institutional delivery, child health, health education
Safe motherhood, child health, family planning, immunization
Support in prevention programmes, data collection, and health campaigns.
Health education, treatment of basic health problems, collect health information, and make referrals to health centres
Training
3 months
23 days
18 days
14 days (2 weeks)
28 days (4 weeks)
Remuneration(y)
USD 1650
USD 500
USD 75
No remuneration
USD 52

3. Community Health Workers in South Asia: A Background
CHW in South Asia:
Sri Lanka: no large-scale CHW programme.
Bangladesh: CHWs program reliant on the NGO.
India, Nepal and Pakistan: large-scale, nation-wide and government-led CHW programmes – more than a million workers.
Case Studies: political context varies, healthcare systems have similarities characterised by underfunded public sector facilities, large private sector involvement, poor health outcomes, large skilled healthcare workforce shortages

4. CHWs: an important part of national health systems
CHWs provide an essential linkage between vulnerable population in rural and poor communities and the formal health system.
They collect information from the community through house to house visits and bring it back to the local health facility.
They carry basic health resources (vitamins, contraceptives, health education tools, etc) from the local health facilities into the community and distribute them as required.
Routine work-time load (5-6 hours daily) in addition to irregular / emergency situations
CHWs represent a substantial portion of the healthcare workforce:
FCHVs = 3 x the workforce of physicians, nurses and midwives combined. LHWs = 43% of this workforce and ASHAs = 46%.

5. CHWs as volunteers: systematic denial of workers rights
Government decides of the broad framework and specific tasks.
CHWs are directly supervised by officers of the health system (no contractor). Yet not recognised as government employees (Nepal and India). Disguised employment.
Minimum wages are denied
Employment benefits: maternity leave, paid leave, social security are denied
Pakistan: Struggle for regularisation led to positive outcomes in terms of access to education (83% children go to school), access to health services and medicines (70% hh have a chronic disease patient), nutritious foods.
LHWs income is 69% of family’s income.

6. Undervaluing healthcare work: The instance of CHWs
Women's labour force participation rate in South Asia: 30.5% (in 2010), mostly within the informal sector or informal component of the formal-economy.
Found the lack of alternative work opportunities to be an important factor in decision to work as CHWs in the 3 countries.
In three countries – caring for the community is constructed to be a natural expertise and obligation of women and thus a calling and not work.
As a consequence, CHW are either unpaid or extremely low paid compared to any worker (let alone same skills and qualifications)
Nepal: annual remuneration comparable to monthly wage for a driver in health system (minimum unskilled wage). In India: around half.
We argue that in Nepal and India, FCHVs and ASHAs provide a hidden subsidy to the national health system (NPR 4 billion, USD 39 milion).

7. Conclusions
The narrative of LHWs, ASHAs (CHVs), FCHV as volunteers does not hold closer scrutiny. Yet, a transition from their current status to a regularisation needs to be a progressive process. It is important that govt. engage in identifying the required steps – regular honorarium as a step to a monthly salary.
Highlight the importance of collective action in ensuring the regularisation of LHWs in Pakistan. One more instance of the universally recognised role of trade unions in improving the working conditions and employment of women.
Judicial system / courts can play an important role in clarifying the status of CHWs. Pakistan: SC directed to government to regularise LHWs – Monday next week (5 February) SC of India final hearing on regularisation of the CHVs from the Bombay Municipal Corporation (BMC). Watching for the right decision from the honourable SC.