Early Years of Community Health

5In 1938, the Indian National Congress set up the National Planning Committee or NPC under the chairmanship of Jawaharlal Nehru, with the vision of providing concrete plans for the future of independent India. However, the actual publication of the plan only took place in 1948, a year after the official independence from colonial rule. By this time, there were three other independent efforts at planning that had been made by different groups in India. Imrana Qadeer lays out the broad strokes of each of the plans in ‘Health Planning in India: Some lessons from the past’ (Qadeer, 2008). The other independent efforts at planning were the Bombay Plan proposed by a group of industrialists (Thakurdas et al., 1944), the People’s Plan drawn up by the Post-war Reconstruction Committee of the Indian Federation of Labour (Banerjee et al., 1944), and the Gandhian Plan with a foreword by Gandhi himself (Agarwal, 1944). These Plans were set within different frameworks of economic development. None went into the details of health planning but provided an overall framework for the sector.

6The Sokhey sub-committee of the NPC, on the other hand, focused on health and highlighted poverty in India as being the root cause of disease. Therefore, the immediate suggestion made by the Sohkey sub-committee was to train an army of grassroot health workers to provide immediate basic care while building the required infrastructure to support them (National Planning Committee, 1948). The committee referred to this as a ‘cornerstone of their recommendations’, suggesting that India’s health planning should incorporate a cadre of community health workers. The initial recommendation focused on rural areas, with one community health worker per 1000 village population, who would be trained in practical community and personal hygiene, first aid, and simple medical treatment, with emphasis on social aspects and implications of medical and public health work. It also recommended that ‘practitioners of ayurveda and unani systems were to be drawn into the state health systems, after giving them further scientific training when necessary’ (National Planning Committee, 1948).

7This was one of the earliest recorded attempts at setting up a large-scale community health system in India, and echoes of the recommendations of the Sokhey sub-committee are visible in the later implementation of the Village Health Guide Scheme. However, due to the multiplicity of Plans by 1948, each with a different focus area, the government decided to set up its own committee to review the recommendations of the plans and come up with a viable system of planning for India. This committee was popularly known as the Bhore Committee.

8According to Qadeer, the Bhore Committee evolved ‘a complex, though unified and integrated system with different levels of health services and a built-in referral system for providing universal basic care’ (Qadeer, 2008). Focusing on women and children, controlling major communicable diseases, and monitoring to provide feedback into the planning process were its central concerns (GoI, 1946). It was guided by principles such as ‘nobody should be denied access to health services for his inability to pay’ and a focus on rural areas, with emphasis on preventive measures and training of what it called ‘social physicians’. The inclusion of the term ‘social physicians’ in the Bhore Committee report is particularly noteworthy, as it laid the foundation for many of the recommendations that were then taken forward by the government in the form of policy measures and community healthcare schemes. The focus on community health in India therefore predated the widely cited Alma-Ata Declaration of 1978, which emphasised a global need for social and community based understandings of health systems across the world, particularly in the so-called less developed countries.

Alma-Ata and International Discourses of Community Health

Community health workers should be members of the communities where they work, should be selected by the communities, should be answerable to the communities for their activities, should be supported by the health system but not necessarily a part of its organization, and have shorter training than professional workers (WHO, 2007).

9The Declaration of Alma-Ata (1978) affirmed that health—‘a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity’—is a fundamental human right and that governments the world over have a responsibility to provision adequate resources to secure the health and the social determinants of health of their people. The Declaration also played an important role in defining the role of local participation within health development programmes. For example, Article VI of the Declaration defines primary health care and its relationship to participation: ‘Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation.’ Article VII emphasises that primary health care ‘requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate.’ Article IV, the most succinct, simply says, ‘[t]he people have the right and duty to participate individually and collectively in the planning and implementation of their health care.’

10These articles—with their language of ‘full’ and ‘maximum’ participation of communities in not just the implementation but also the planning and control of health programmes—clearly connect local participation in primary health care to a pursuit of social justice, the goal of equitable distribution of power, resources, and wellbeing (Muller, 1983). The Declaration’s emphasis on participation sent the message that health equity requires not just ‘appropriate methods and technologies’, but the ability of previously socially and politically marginalised people to control their health care system and hold states, donors, and health development foundations accountable.

Village Health Guides

11The Village Health Guide (VHG) Scheme was implemented in India in 1977, a year before the Declaration of Alma-Ata. Beginning as a relatively smaller set of grassroots projects towards community health, the VHG Scheme went through numerous changes and attempts at scaling up the size before it was ultimately scrapped. The VHG provides an important starting point, both to observe the challenges and pitfalls associated with ‘scaling up’ smaller programmes at national levels, and because it has been cited as serving as the basis for the newer ASHA scheme in particular.

12Going back to the recommendations of the late 1940s and early 1950s as outlined in the previous section of this chapter, Strodel and Perry (2019) illustrate the gap between the policy recommendations and actual practice at this stage. They argue that rural health centres were being used for almost double the intended population sizes and that the lack of transportation development meant that only certain sections of the rural population could utilise these resources.

13Due to these issues which continued to persist in the 1960s and 1970s, the Ministry of Health and Family Welfare launched the Srivastava Committee in 1974 (formally referred to as the Health and Medical Education Committee). It was this committee that incorporated earlier recommendations of the NPC and Bhore committees into planning the VHG Scheme. Strodel and Perry (2019) outline some of the key points of this decision in their article ‘The National Village Health Guide Scheme in India: lessons four decades later for community health worker programs today and tomorrow’.

14The recommendations on paper were to have a cadre of existing health workers who would provide outreach for the community, such as auxiliary nurse midwives (ANMs). However, the programme also included training other community members who had attained a certain level of education such as schoolteachers, or literate unemployed women. These community health workers were to be selected by the community, who also had the power to remove a VHG from their position if they felt that the duties were not being performed well. The VHGs were trained to identify cases of communicable disease, treat minor illnesses and injuries and promote awareness about sanitation and hygiene.

15There are certain interesting discrepancies, both intentional and unintentional, between the recommendations of the Srivastava Committee and the implementation by the Janata Party. First, the committee made a point to recommend that these workers should not be paid at all, citing that it would disturb the trust between the VHGs and the communities if there was a form of monetary compensation involved. However, the government decided to pay the VHGs a token honorarium - INR 200 during the months of training and INR 50 per month after that, according to Strodel and Perry (2019). While this honorarium was nowhere near enough to cover basic monthly expenses, Strodel and Perry argue that the decision to pay the workers was not due to a different understanding of their labour as deserving of payment, but rather a calculated political decision. As a party that had just been elected to power, the Janata Party needed to show that this initiative was providing employment to the people, especially women, and was decreasing unemployment rates in the country.

16Second, the Srivastava Committee recommended that there should be an almost equal number of male and female VHGs, that is, one male and one female worker per 5,000 population. However, this was not translated into practice as the planners did not specify any gender-based requirements (but did add that the workers should be female ‘wherever possible’). This led to a highly skewed gender ratio of VHGs, with upwards of 75 per cent of VHGs in the country being men. This is one of the major changes that is visible between India’s early attempts at community health, and later schemes which are designed around the idea of female community health workers.

17Finally, it is worth noting the changing nomenclature of VHGs. Initially the scheme was called the Community Health Worker Scheme, which was changed to the Community Health Volunteer Scheme in 1979, and then finally the National Village Health Guide Scheme in 1981. Terms such as volunteer, guide, and activist often replace ‘worker’ in government-mandated social welfare schemes, often in tandem with payment practices that are not salaried, but rather, honorarium or incentive-based. These practices can be seen as indicative of a larger and more complex divide between worker and volunteer, paid work and less-paid work, which are upheld by governmental policies at the detriment of these workers. The subtle shift from worker to volunteer, guide or activist is further accompanied by a form of payment that does not legitimise them as employees of the state but puts these workers in a liminal space of simultaneous employment and non-employment, paid and yet unpaid. The fact that this mode of work-volunteerism has carried on from the 1970s to the present day, specifically within this area of the state, calls for further reflection on how the state views and negotiates the care work and labour that goes into the health of its population, and more specifically, the care of large segments of the populations that are socio-economically and locationally disadvantaged to access health infrastructures and technologies that are made available to the more well-off classes. Both Dasgupta and Qadeer critique the very ideology of community health work in this vein, arguing that by implementing such schemes for a select section of the population further reduces the state’s responsibility by putting the onus on uniquely exploited workers, who are usually women (Dasgupta and Qadeer, 2005).

18Anthropologist Mark Nichter (1999) describes India’s mid-1970s implementation of community health worker programmes that were supposed to give CHWs the power to ‘develop culturally sensitive health education messages responsive to local resources and health practices’, but which in the end led to the creation of ‘another cadre of paraprofessional health workers responsible to the health centre, not the community.’ According to Nichter, higher-level health staff wanted to control community health workers, rather than allow community health workers and the people of their own communities to control the health system. This illustrated ‘the tendency of the health care bureaucracy to resist innovations which undermine pre-existing power structures’ (Werner et al., 1981; Standing and Chowdhury, 2008).

19The VHGs were intended to be a cadre of health workers tasked with a broad array of duties related to preventive, promotive, and curative services, as well as advocacy and education. Due to poor communication between the central government and rural communities, the VHGs’ promotive and preventive roles were neglected, and their work became focused on curative tasks. Furthermore, poor coordination between the central government and state actors led to weak implementation of even those curative responsibilities, with almost half of all VHGs lacking their essential drug kits in 1979. What began as a programme with the potential to empower communities ultimately disintegrated because of inadequate support and insufficient changes in the structure of the existing health system. The VHG Scheme was eventually followed in 2005 by the Accredited Social Health Activist (ASHA) programme, introduced on a national scale in India by the government’s National Rural Health Mission, which claims to draw on lessons from the VHG Scheme.

ASHAs and the National Health Mission

20The National Rural Health Mission (NRHM) was launched on 12 April 2005 to provide ‘accessible, affordable and quality health care to the rural population, especially the vulnerable groups’ (Government of India, 2005a). According to the original policy documents, the NRHM seeks to provide equitable, affordable and quality health care to the rural population, especially the vulnerable groups. Under the NRHM, the Empowered Action Group (EAG) States as well as Northeastern States, Jammu and Kashmir and Himachal Pradesh have been given special focus. The thrust of the mission is on establishing a fully functional, community owned, decentralised health delivery system with inter-sectoral convergence at all levels, to ensure simultaneous action on a wide range of determinants of health such as water, sanitation, education, nutrition, social and gender equality. NRHM focuses on Reproductive, Maternal, Newborn, Child Health and Adolescent (RMNCH+A) Services. The emphasis here is on strategies for improving maternal and child health through a continuum of care and the life cycle approach by highlighting the complex relationships between adolescent health, family planning, maternal health and child survival. The linking of community and facility-based care and strengthening referrals between various levels of the health care system to create a continuous care pathway was also a key focus of the NRHM (Government of India, 2005a).

21The ASHAs (who are addressed through this acronym by all) are village-level health workers who have been recruited since the start of the NRHM in 2005. One ASHA is responsible for a single village (population of about 1000). They are recruited on a voluntary basis from the village by the local government village representatives and are supposedly accountable to the community. ASHAs receive about three weeks of training over five rounds, focusing on their role as a link between the health system and the village. The training sessions continue periodically over two years and are usually more specialised for particular community health initiatives after the initial round of training. ASHAs are responsible for mobilising the community to access public health services, including immunisation, hospital birth and antenatal care (ANC); identifying and referring people affected by tuberculosis, leprosy and malaria; and promoting family planning programmes. Apart from this, they have a broader role of being health activists in the community by creating awareness about health and its determinants, mobilising the community towards local-level planning and increasing utilisation and accountability of existing health services (National Institute of Health and Family Welfare [NIHFW], Government of India, 2005). ASHAs as ‘change makers’ and ‘activists’ within the community is further visiblised in the language used in official policy documents and reports. The Guidelines on ASHAs, published by the National Health Mission, state that the ASHA scheme was launched in part to fulfil the gap that was left by the existing Anganwadi and ANM programmes:

Currently Anganwadi workers (AWWs) under the Integrated Child Development Scheme (ICDS) are engaged in organizing supplementary nutrition programmes and other supportive activities. The very nature of her job responsibilities (with emphasis on supplementary feeding and pre-school education) does not allow her to take up the responsibility of a change agent on health in a village. Thus a new band of community based functionaries, named as Accredited Social Health Activist (ASHA) is proposed to fill this void. (National Health Mission, 2004)

22ASHAs are paid performance-based cash incentives, the amount of which differs according to the nature of the service. For example, distributing Oral Rehydration Packages to the community is an incentive of INR 1 per package, while assisting and supporting a pregnant woman in the community until full-term labour is around INR 300. The ASHAs receive a fixed ‘honorarium’ each month, the amount of which varies from state to state. Even though the general framework for the ASHA scheme is set up by central guidelines under the nationwide National Health Mission, the precise responsibilities and tasks of the ASHAs, as well as the monthly honorarium and monetary value ascribed to each task varies according to different states. In December 2013, following a strike which was coordinated by ASHA workers’ unions across the country, a fixed monthly honorarium of at least INR 1,000 was announced by the central government. Some states, such as Maharashtra and Kerala, announced the introduction of honorariums above that level as well (ILO, 2018).

23The use of the term honorarium rather than salary or wages denotes that ASHAs are not full employees without the benefits and stability that a salary connotes. In the early guidelines published by the National Health Mission (NHM), it was stipulated that the ASHAs would not in fact be entitled to a salary or honorarium, citing that they are honorary volunteers and hence will not receive such monetary benefits (National Health Mission, 2004). However, this has since changed but the implications of receiving less to no money because of the nomenclature and presupposed nature of their work and relations with the community still underpins the ways in which ASHAs are viewed and treated by state authorities.

24The honorarium usually ranges from INR 3,000 to INR 5,000 in 2023, which is supplemented by the task based incentives. Some of the ASHAs in Delhi whom I interacted with, who have a larger number of houses under their purview, manage to make around INR 10,000 a month while others make closer to INR 7,000 on a regular basis. ASHAs in rural areas make significantly less per month, as compared to urban ASHAs in large metropolises such as Delhi and Mumbai (Government of India, 2020). Recently, states including Maharashtra and Kerala have made the decision to increase the honorarium of ASHA workers in their regions by INR 1,500 (Times of India, 2023).

25Above the ASHAs are Anganwadi Workers, who are incorporated into the Integrated Child and Development Services (ICDS) Scheme. Anganwadi in Hindi translates to a ‘courtyard shelter’ in English, and Anganwadi centres are essentially childcare centres which are dotted across neighbourhoods and villages in the country. The Anganwadi worker is a member of the community, who is tasked with taking care of the young children in the neighbourhood, supplying them with nutritious food (which is provided to them each day), and tracking their growth and nutrition intake. Each Anganwadi worker also has a helper, who assists the worker in ensuring the smooth functioning of the centre on a daily basis. Unlike the ASHAs, however, the Anganwadis are paid a fixed monthly salary of INR 10,000 per month. The Anganwadi scheme also significantly predates the ASHAs, going back to the 1980s, which led to the earlier formation of the Anganwadi Union, which was able to advocate for a fixed salary structure with the central government.

26Above the Anganwadis are the ANMs or Auxiliary Nurse Midwives who are also village-level female health workers. They work mostly in the health sub-centres, which are under the Primary Health Centre of an area. The ANMs are multi-purpose health workers, responsible for carrying out immunisation programmes, assisting in maternal health and family planning, reproductive health services, and so on.

27The three cadres of health workers outlined above have complex hierarchical relationships, further intensified by the different payment structures and subsequent respect they garner. While ASHAs and Anganwadis are considered to be CHWs according to international definitions, such as the one provided by the WHO at the beginning of this section, auxiliary or middle-level health workers such as the ANMs are generally facility-based, that is, they work through the facilities of primary health care centres, and do not fall within the same category (ILO, 2018). The Anganwadi is a little outside the purview of the ANM however, who is directly responsible for the 4-5 ASHAs that usually fall within the geographical ambit of the ANM’s work. The ANMs and ASHAs are supposed to meet fortnightly or weekly in order for the latter to update the former on the work that was done during this time. The ANMs also act as a resource person for the training of ASHAs. The two groups of health workers also form a bridge between the community and the health system: the ASHA brings pregnant women, children for immunisation, and couples for family planning to the ANM. During my fieldwork, I interacted with each of the groups of community health workers in different capacities. Furthermore, I also observed immunisation camps that were being held during the time of my fieldwork, which is one of the coinciding tasks of all three.

28The modes of payment, roles assigned, and engagement with the community for all three types of health workers differ to varying extents - however, the fact that they are all women who in some capacity, have been tasked to take on the ‘care’ of their communities points to larger questions regarding how the Indian state views labour, care work, and women’s work. The ASHA’s precarious position within the Indian healthcare system has been a matter of much contention for the past few years. There have been numerous labour strikes and protests by the workers, demanding a salary-based rather than incentive-based form of compensation. Particularly during the COVID pandemic, ASHAs were the main frontline workers, working gruelling hours in dangerous conditions, with little to no support from government authorities. Payment to the workers was further delayed during this time, with the governments citing slow working conditions due to the pandemic. Numerous newspapers and media outlets covered the situations of ASHA workers during the height of the pandemic in 2020 and 2021. While the honorarium has been steadily increased for the ASHAs since 2004, there is still resistance to making the ASHAs full employees, or even giving a fixed monthly honorarium like the Anganwadis.

29This research explores the various reasons for this resistance, and in doing so, attempts to understand how and why such contours of work within community health are drawn in the first place. The main arguments of this paper therefore rest upon untangling the complex nature of the state’s relation to women’s work and unpacking how and why such uncertain spaces of employment continue in the formal economy.