Abstract
There is increasing informalisation in the public sector workforce, especially at the lower levels. Women form a huge part of the informal labour force. The health sector is also witnessing similar trends where another concept of ‘volunteerism’ is also emerging, as seen in the Mitanins of Chhattisgarh. The Mitanin programme, considered to be a precursor to the accredited social health activist (ASHA), had started on a different note. It had hoped that the community will pay for the loss of wages in future, instead of the government, so that the Mitanin remains a community representative. In the initial couple of years, the Mitanins were not compensated and later, activity-oriented payment was started, thus leading to incentivisation of their activities. Post-National Rural Health Mission (NRHM), this mode of compensation got cemented. This article will explore how one of the most important agendas during the conceptualisation of the programme, of the Mitanin being able to raise the community’s concerns and demands, being a community representative and organiser, was not met and she became a very lowly paid, honorary worker of the government health service system. This article is based on extensive fieldwork conducted intermittently between 2004 and 2008.
Introduction
The concept of the community health worker (CHW) 1 has been in existence for a long time under different nomenclatures in different parts of the world. India has had its share of small-scale as well as nationwide CHW programmes. 2 In 2002, the Mitanin programme was started in Chhattisgarh, where women CHWs based in hamlets were selected by the same community. Each village may have more than one CHW, as a Mitanin may serve as many as 50 households depending upon the size of the hamlets. Learning from past CHW programmes, in order to address the issue of caste, the Mitanin programme introduced some changes such as that each hamlet would be a unit for the Mitanin rather than the whole village. There is an elaborate process of selecting the Mitanin by the community for greater community ownership, 3 followed by continuous training. There is a dedicated parallel structure of trainers. Curative care was introduced only after a few rounds of training. Initially, no monetary compensation was announced for services provided by the Mitanin.
The Mitanin is regarded as the precursor of the accredited social health activist (ASHA), who is a pivotal component of the National Rural Health Mission (NRHM) launched in 2005. ASHAs are selected from the village and are supposed to function as an interface between the community and the public health system. Since Mitanins belong to the same village and are selected by the community rather than appointed by the government, they are expected to be accountable to the village. Initially, Mitanins were not compensated for their work. Rather, the state envisaged compensation from the community in some form when their contributions became apparent. However, when the ASHA programme was launched three years after the Mitanin programme, incentives were announced during the time of selection itself. They were introduced in the capacity of ‘honorary volunteers’, who would be paid incentives by the government (Government of India [GoI], n.d.), though increasingly, there have been various demands from the ASHAs to have a fixed pay. Interestingly, CHWs across the world have worked as volunteers, though sometimes supported by the community or ‘rewarded’ (paid honorarium or salary) by the government (Prasad & Muraleedharan, 2007).
Context
The push for privatisation, competition and the thrust to reduce government expenditure contributed to increased informalisation of the global workforce despite a rise in employment across all sectors, including the health sector. With the collapse of the welfare state in the 1970s, India ‘succumbed’ to the reform policy pressure ‘informally during 1980s and formally in 1992’ (Qadeer, 2011). The 1993 World Bank report, Investing in Health, too recommended: ‘protect non-salary spending by introducing more flexibility into their hiring arrangements’ (World Bank, 1993, p. 127). As an outcome, focus on rural health services was reduced, accompanied by a withdrawal of state investments in health (Qadeer, 2011). Emphasis on cost efficiency and budget issues impacted health care workforce reform, with reliance on new public management principles, markets and flexibility in employment, financial incentives and organisational changes. This changed the way lower-level health care workers were recruited and treated (Roy, 2010). Studies show that post-reform, newer gendered categories of health workers were created (Kuhlman, Bourgeault, Larsen & Schofield, 2010). Attempts to address the shortage of manpower were later promoted through ‘task shifting’ as it had ‘potential for wider health system strengthening’ (World Health Organization [WHO], 2008). In task shifting, ‘specific tasks are moved, where appropriate, from highly qualified health workers to health workers with shorter training and fewer qualifications in order to make more efficient use of the available human resources for health’ (WHO, 2008). This report also noted the need for heavy investment combined with other strategies to increase workforce, as task shifting cannot be the only solution. However, Lehmann, Damme, Barten and Sanders (2009) argue that for long-term success, task shifting needs serious political and significant financial commitment.
After the introduction of structural adjustments in the 1980s, Lehmann and Sanders (2007) noted that most large-scale and national CHW programmes collapsed worldwide. When these resurfaced, there was a shift in the nature of CHW programmes. The authors observed that ‘their role as advocates for social change has been replaced by a predominantly technical and community management function’, even though they continue to bridge the gap between communities and health services. Moreover, there was a renewed focus on CHWs recognition that the existing health services and their personnel are not able to meet the needs of remote and underprivileged communities (Lehmann & Sanders, 2007). In India too, as health services have not been able to address the shortage of personnel in the rural and urban areas, programmes like that of the Mitanins become relevant.
Worldwide, women form a huge part of the informal workforce. They are preferred as informal workers since they appear more submissive and are less likely to form unions or demand high wages. For the same reasons, they are unemployed during times of recession (Ghosh, 2004). Chen (n.d.) says that women’s time and mobility are constrained due to social and cultural norms that assign them responsibility for social reproduction and discourage investment in their education and training. This weakens their position in the labour market. Thus, traditionally, women volunteer for social welfare services in far greater numbers compared to men (Baldock, 1998). Baldock argues that especially in social welfare, this differentiation is due to structural factors. It is not just due to a woman’s position in the family but also because of organisations that marginalise women’s labour. She argues that in social welfare, women volunteers, like paid women workers, ‘form flexible and expendable pools of labour, available to take up volunteer work when government reduces expenditure by contracting out and privatizing services to the non-government sector’. Due to the social perception of women’s role, they are assigned the role of caregivers within health systems as well (Baldock, 1998). As Kuhlman et al. (2010) point out, the image of biomedical cure is linked to the skills of doctors and the feminised image of care work with nurses. Similarly, CHWs across the world are predominantly women, even though in some countries programmes have men as CHWs (Lehmann & Sanders, 2007; Prasad & Muraleedharan, 2007). In India, in the 1970s, most CHWs were male. However, there has been a shift in policy towards replacing male workers with female workers at the community level (GoI, 1997, as quoted in Prasad & Muraleedharan, 2007). In the Mitanin programme, women are chosen as Mitanins because of the social and cultural norms and the assumption that
women are better able to reach out to women…the cultural conditioning as natural caregivers to the family makes women look at health care as a necessary area of intervention…There is lesser tendency of women to settle down as quacks. (State Health Resource Centre [SHRC], 2003, pp. 20–21)
At present, they are treated like honorary workers with an uncertain future. If CHWs function as an arm of the government, they will be reduced to last-mile contract workers, subservient to the health system.
This article studies the Mitanin programme in Chhattisgarh and its move from one of unpaid volunteers to being incentivised for piecemeal work. A CHW programme revived post-reform. It was then scaled up into ASHA through the NRHM. I explore the journey of Mitanins and show how restructuring of the public health sector co-opts the notion of CHW and turns Mitanins and ASHAs into underpaid workers and delegates to them the critical work of linking village communities with health services. Data collection for the study on which this article is based took place in two phases: first, between 2003 and 2004 (before the incentives were started); and later, between 2006 and 2008 (after the incentives were introduced). In the first phase, the study was done in two pilot blocks of Dhamtari and Rajnandgaon districts and implemented by a non-governmental organisation (NGO) and the district health service respectively. In this phase, 72 Mitanins were interviewed, so as to understand their work and programme implementation when no incentives or honorarium was announced. In the second phase, fieldwork was done in one block of Rajnandgaon district, where 52 Mitanins spread over 23 villages were interviewed. This block has four sectors and two trainers and their Mitanins were chosen from each sector. Trainers at the block level and key personnel at different levels were also interviewed in both phases through open-ended interview schedules. Home visits in both the phases, as well as observing immunisation, sterilisation camps and attending different activities, like trainers’ meetings, cluster meetings, auxiliary nurse midwife (ANM) meetings and staff meetings of community health centre (CHC), formed part of the fieldwork.
Mitanin Programme: Debate on Incentives
Following prolonged consultations with civil society, the Mitanin programme was conceived after the formation of the new state of Chhattisgarh to address the poor health status of its people and gaps in health care infrastructure (Som, 2004, 2009). Initially, a state government order, dated November 2001, specified that ‘no honorarium or pay shall be paid to the Mitanin by the Government; however the village community itself can compensate her for her efforts by pooling money or grains’ (as quoted in Misra, 2011). The issue of honorarium was well debated in various forums, including an important workshop held in 2001 (Government of Chhattisgarh [GoC] & ActionAid Chhattisgarh, 2002). A Mitanin would be part time, requiring to work no more than 8–10 hours per week, which would not affect her livelihood tasks. Also, the monetary compensation, if paid to the Mitanins, would be nominal. Further, there was an underlying assumption that the communities might not come forward to support the Mitanins if they are paid for their work by the health department. The community may then perceive Mitanins as ‘…an organiser of women and the community, from being seen as representative of community monitoring the health services on their behalf, paying her would make her the lowest paid employee of the department with all its attendant consequences’ (SHRC, 2003, p. 25). Another aspect which concerned the planners was that this CHW programme may lose its spirit and inherent nature as reimbursement for their work may give greater control to the state bureaucracy (GoC & ActionAid Chhattisgarh, 2002). It was noted that an assured income may result in the expectation of a salaried job, regardless of the quantum of payment. On the other hand, the absence of any honorarium would discourage influential people in the community from interfering in the selection process. There was an apprehension among the planners that a separate cadre may also lead to the problems of unionisation, demands for increased wages as well as regularisation, and ‘this would imperil the community based health programme’ (GoC & ActionAid Chhattisgarh, 2002).
At the same time, it was clearly recognised and stated that the Mitanins need to be compensated in some form; else the programme would be unsustainable. It was also recognised that expecting a poor woman to volunteer would be unjust ‘and discriminatory not to pay...—the poorest in the chain—for her services’ (SHRC, 2003). From the discussion, it emerged that the state wanted to shift the responsibility of compensation to the community, but, overall, there were a lot of other concerns like how would the community pay: in cash or kind, or set aside land as Mitanin land or divert some amount to be paid from the other health programmes. However, the government’s decision whether to pay the new CHWs, and by whom, remained inconclusive (GoC & ActionAid Chhattisgarh, 2002; SHRC, 2003, pp. 12, 63). Payment by the community was preferred as this would also make her accountable to the community, unlike a government employee. It was very clearly stated that the Mitanin is ‘not under the ANM’ and ‘she is a community’s representative to monitor and facilitate government provided health services and to help the community organise self-help measures’ (SHRC, 2003, p. 63). The payment structure was to be decided following the outcome of the pilot phase of the programme. However, hasty statewide implementation of the programme prevented this from happening.
Factors Encouraging Mitanins to Volunteer
The Mitanins had different reasons for joining the programme even when no compensation was announced. These were: gaining knowledge about health that may benefit her immediate family; source of education for those deprived of formal education; nomination by elders of the community; and the power of issuing medicines and getting associated with the health department. Baldock’s (1998) study showed that when women volunteer, they do so not only for altruistic motives but also for those ‘relating to personal development and the need for social interaction’. They see volunteerism as a process of empowerment. She added that volunteers have gained more significance now when there is contracting out of government services and increasing privatisation. The volunteers too realise their contribution to the welfare of their community, thereby gaining self-confidence (Baldock, 1998). In the Mitanin programme, the close association with the government health services gives an added incentive and the field of health has a certain respectability in the community.
Though Mitanins joined the programme with no hope for monetary compensation, a few facilitators did hint of such a possibility in the future. Some enjoyed their work and believed that the knowledge gained would help them in their homes as well. Initially, excitement of being a part of the programme meant that Mitanins did not pay much attention to the issue of monetary compensation (Som, 2004). However, it was not long before a number of women wanted some sort of compensation, since their families felt that they should be rewarded for investing their time and energy. During initial days, the Mitanins spent time on house visits, attending training courses, meetings and trainer’s visits. The government health workers, like ANMs, multi-purpose workers (MPWs) and lady health visitors (LHVs), also expected the Mitanins to accompany them during their visits to the village. As a consequence, some families from the study areas complained that the women were spending time but not getting anything in return, while some Mitanins believed that they would be compensated after completion of training.
After the launch of NRHM in 2005, task-based incentives were introduced for specific activities like immunisation, distribution of tuberculosis (TB) medicines, accompanying women for institutional delivery etc. However, incentives were initiated and continued with the state government following the national guidelines of NRHM, and ASHA funds were used for funding the Mitanin programme, including the newly introduced incentives. This diverged from the spirit of the Mitanin programme as any payment would associate such women with government health services and the community would withdraw.
Incentives, No Incentives and Changes in Mitanin’s Work
The introduction of incentives brought many changes in the Mitanins’ work and ensured that they focused on specific and tangible tasks. Activities with immediate achievable targets gained centre stage in the interaction between the trainer and the Mitanins. Trainers were asked to focus on activities like immunisation, Janani Suraksha Yojana 4 (JSY) and sterilisation, as these were used to assess health services. Health services saw the village-based Mitanins as a cadre that could help them achieve their targets. Incentives became an effective tool towards this end and other activities not covered by incentives were not actively encouraged. Thus, the attention and time of the Mitanins was diverted from activities like promoting breast feeding, maintaining cleanliness near public hand pumps in the village and sharing knowledge in village meetings on better health practices. These were, in fact, neglected.
Activities with Incentives
Even though the incentive was very small and limited to a few activities, people in the village saw the Mitanin as a representative of the health service system. The change from being a volunteer to being paid for specific activities also changed the Mitanins’ relation with other workers in the village, namely, the ANM and anganwadi worker (AWW). Here, we focus on the subtle friction seen between the Mitanins, ANMs and AWWs, and the hierarchy emerging.
Prior to the launch of the Mitanin programme, for routine immunisation in the village, the ANM used to take the help of the AWW or the anganwadi sahayika (AWS). Using the anganwadi as the immunisation centre in villages which did not have sub-centres, AWWs and AWSs used to gather all the children and pregnant women for immunisation. However, after the Mitanins started getting incentives (₹ 50 per month), it was observed that in many places, the AWWs felt that it was no longer their task, but that of Mitanins. Significantly, as 12 per cent of the Mitanins interviewed were also working as AWWs or AWSs, few people in the village questioned the practice of a single person holding multiple posts. Such queries began only after incentives were announced for the Mitanins.
Initially, in order to achieve their targets, ANMs used to ask Mitanins to find and motivate cases for routine sterilisation from the village. In October 2007, an incentive of ₹ 150 was introduced for Mitanins who brought a sterilisation case to the health facility. The ANMs and Mitanins worked together for finding cases. Another circular in January 2008 stipulated that anyone who motivated and accompanied the person to be sterilised to the health facility would be eligible for the incentive. Soon, ANMs and Mitanins were competing for the same incentive, leading to arguments and conflicts. In one case, the ANM told the women in the village that the Mitanin need not be involved in the sterilisation operation. When this was brought to the block medical officer’s (BMO) notice, he warned the ANMs against such incidents. One ANM argued with the BMO saying that all the money should go to ANMs and there should not be any sharing. In another case, a village meeting was held to resolve this. Expressing dissatisfaction, one Mitanin said, ‘I rather say that do not give money. If you are giving, then give it properly or else do not give’ (Som, 2009).
The number of houses for each Mitanin was decided at the time of selection, but this was not considered significant until the time of JSY. Though 50 was the ideal norm of households per Mitanin, 27 per cent of the Mitanins worked on less than 35 households and 19 per cent had more than 80. A Mitanin was expected to take a pregnant woman to the health facility from her own hamlet. Any violation led to tension among the Mitanins. Mitanins used strong persuasion with the family and the pregnant woman for institutional delivery arguing that this was safer than births at home. However, the health system at this time was not prepared to take on this load and there were several instances where the supposedly ‘safe’ institutional delivery was questionable. In some cases, as the ANM lived in another town/village, by the time she arrived, the delivery had been conducted by the dai and the Mitanin. In another sub-centre, the ANM used a charpai (cot woven with rope commonly slept on in villages) for deliveries, while in another case, as there was no electricity, the ANM had to make do with a lantern. Nor was it unknown for inconvenient transportations like motorcycles being used to take women in labour to a Primary Health Centre (PHC). Despite these issues, the Mitanins tried convincing women that institutional deliveries—the largest source of income for them—were safer. Prodding by the health officers, coupled with the hope of incentives, strongly influenced the Mitanins, often to the detriment of their other public health activities.
Tasks with No Incentives
Some of the major, non-incentivised Mitanin-initiated health services activities were: providing medicines, taking referral cases and making blood slides for malaria detection. Other tasks included regular house visits, monthly village meetings, cleanliness and hygiene-related education in the village, advising pregnant women, taking issues to the panchayat and attending cluster meetings. Right from the beginning of the programme, providing medicines was one task that the Mitanins eagerly looked forward to, and were keen to do well. However, erratic supply of drugs from the health department soon dampened their spirit as they lost the trust of the people. Though ANMs were instructed to share their quota of medicines with the Mitanins to alleviate the shortfall, the problem persisted. There were times when the Mitanins did not get their supply of medicine for three months (Som, 2009). As one said:
If a patient comes and we cannot give medicine then people will stop coming to us. You also need to give a full dose and not hand over just one medicine because only then they will believe that Mitanin has medicines which work. (Som, 2009)
Mitanins also used to make blood slides—though on many occasions, instead of making slides only for patients with fever and symptoms of malaria, instructed by ANMs keen on meeting targets, Mitanins reported making these of healthy children as well! On the other hand, when Mitanins made slides of people with symptoms of malaria, the reports were delayed since the delivery system for these was non-existent. The blood slide went to the CHC and it took more than a week to get the report, by which time the patient would have approached a private practitioner. Without adequate support from the health services, making slides became a fruitless exercise.
For referrals, the Mitanin was supposed to carry a paper slip, one part of which was to remain with the doctor and another part, citing the diagnosis of the patient as well as the treatment, was to be returned to the Mitanin. It was a simple exercise, but apart from the BMO of the CHC, no other doctors in the district hospital, CHC or PHC bothered to keep or return the filled-in slip. Thus, this exercise too was of little use. As there was no institutionalised referral chain, only 31 per cent of Mitanins reported having referred cases (apart from sterilisation and delivery cases) to the health services at any point in time.
In the initial stages, the house visit was very important as it helped the Mitanin to familiarise herself with families and establish their health status. A Mitanin commented:
there are very small things that we can tell the people like nutritious food, cleanliness, prevention of malaria—by using oil or gambujiya fish for pits,
5
mosquito nets; prevention of diarrhoea. During the rainy season we tell them about keeping the food covered, and boiling drinking water. These are small things but very effective. (Som, 2009)
The house visit was discontinued after the first few rounds of training, as the trainers did not stress on it. After the introduction of JSY, house visits once again gained importance, though only houses with pregnant woman and infant children were visited. When Mitanins visited pregnant women, their main objective was to persuade them to have an institutional delivery. This was despite the fact that they were expected to provide information about overall care for the pregnant woman, ranging from the dos during the antenatal care (ANC) period (food, rest and making necessary arrangements) to care for the newborn, etc. But all this became irrelevant due to the focus only on institutional delivery. Very few Mitanins spoke about cleanliness, hygiene and nutrition. Similarly, health committee meetings envisaged as occasions when Mitanins would disseminate information to the community and initiate discussions on health were neglected. Still, the official report always showed a 100 per cent attendance, as a meeting near the pond or in the field with two or three women was considered a health committee meeting. According to our data, this figure was only 16 per cent. Thus, it was not just the absence of incentives but also the lack of basic support services from the health services that was demotivating for Mitanins.
Shifts in Mitanin as CHW
Activities for which Mitanins did not get incentives, like house visits and health committee meetings, did not receive much attention from the trainers, who mainly stressed targeted tasks that were asked for by the health department. Nevertheless, Mitanins were proud to be associated with the ‘health department’ and the incentives further strengthened this new relationship: as incentives were routed through the health services, Mitanins were seen by the villagers as well as by health personnel as paid workers. They were now no longer viewed as being representatives of the community, as originally envisaged.
With the introduction of incentives, the state health department began to command power and ‘control’ over the Mitanin programme. There was a dress code for them in several places like Raipur. However, in Dongargaon, only the trainers were asked to observe such a code. Also, the trainers were now given targets informally for certain national programmes like sterilisation by the block authorities. Mitanin trainers operated a Mitanin help desk in the CHC and at the district hospital. It created the impression that they were part of the health services. Trainers were also supposed to assist on some occasions like the sterilisation day, eye camp and other camps. While there were no official orders to this effect, they assisted the ANMs so as to be in the good books of those in charge of the health services. In turn, Mitanins and their trainers were utilised as the much-needed extra human resources.
Villagers viewed the health system as modern, scientific and superior. Also, the fact that most health personnel like doctors, LHVs and ANMs belonged to the upper castes helped establish their authority. With limited employment opportunities in the village, Mitanins and trainers wanted to be associated with the health department in the hope that they might get secure employment in the system when vacancies arose. The SHRC representative in the district could not interact regularly with Mitanin trainers due to a heavy workload. The trainers had to rely on the health department personnel like ANMs, BMO and the government district resource person (DRP), 6 both for technical and programmatic support. Thus, rather than being mentors, the trainers were reduced to being agents for Mitanins, relaying information and collecting data. Performance-based payment to the trainers on the basis of DRPs assessment made trainers anxious to toe the line. When a Mitanin complained to a trainer about the poor supply of medicines, the trainer retorted, ‘You are never to say that your stock is over.’ If someone looked at the medicine kit, the Mitanin was to say that the stock just got over. The trainer continued, ‘these are things within the department and not for everyone. We have to work together, so why tell others about it’ (Som, 2009). An evaluation pointed out that the health department was more interested in taking control rather than nurturing the Mitanin programme (Misra, 2011, p. 23).
During the time of the study, the Mitanins in Chhattisgarh got ₹ 50 for attending the monthly immunisation sessions in the village, ₹ 150 for motivating sterilisation and ₹ 200 for motivating and accompanying a pregnant woman to the health centre for delivery. A transport charge of ₹ 400 was intermittently given either to the Mitanins or to the women’s families, depending on the relationship of the Mitanin and the family with the ANM. Apart from this, the Mitanin received incentives for administering TB drugs to the directly observed therapy (DOT) patients 7 (₹ 250 per patient after complete treatment). However, the payments were paid at irregular intervals. For example, during 2007–2008, Mitanins and the trainers were not paid for a period of four and six months respectively (Som, 2009).
Incentive Received by Mitanins in Different Districts of Chhattisgarh in Three Months (in ₹)
An assessment of the incentives received by the Mitanins in eight districts of Chhattisgarh for a three-month time period prior to the survey (September–November 2010) showed that on average each Mitanin received less than ₹ 200 per month (Table 1). Payment to the Mitanins ranged between zero to ₹ 4,000 (Misra, 2011). In Koria district, Mitanins received the highest payment of about ₹ 220 per month as some enterprising individuals outside the government machinery had mentored the programme. In essence, it was this small token amount which helped the health services to take control of the Mitanins and their trainers.
In the absence of alternative sources of income, even the minimal incentives received from these programmes become significant. In Chhattisgarh, the small number of households assigned to each Mitanin also limits the potential to increase incentives and the Mitanins as a group are yet to be recognised as workers in the health sector.
Conclusion
In post-reform India, investing in the private health care system has proved to be highly lucrative. However, the growth of curative care, the private high-tech urban medical sector need to be contrasted to the rural health services that have not been given the adequate push and infrastructure (Qadeer, 2011). This is manifested in the spiralling spread of informal practitioners (quacks) in these areas. Further, the support systems of MPWs and ANMs have not been strengthened (George, 2010). To help overcome these lacunae in responding to the needs of the rural population, Mitanins or ASHAs have resurfaced as CHWs, especially in the remote and underserved rural and urban areas. However, as observed in this article, Mitanins have evolved as link workers in the garb of community representatives who pursue the targets of the health department rather than address community needs. In recent times, with increasing support from the WHO, the Indian state and its health system have actively encouraged ‘task shifting’ to address the shortage of human resources in health services.
Women in India are handicapped in accessing affordable health care due to a diminished public health sector. In addition, the state uses poor women as care providers in order to generate greater demand and consumption of allopathic care. As Doyal (2003) points out, after socio-economic reforms, women in developing countries have become the major producers of health care—but with little job security. Further, neglect of infrastructural support in terms of transport and housing has consequences for women health workers (George, 2010). Women are employed as CHWs due to the general view that they are better caregivers and that they can better reach out to other women. At the micro level, and in the long run, being a Mitanin or ASHA for a women becomes a way to secure a social and economic position in the community and contribute to the family. However, at the macro level in the health sector, Mitanins as producers of health care services and their work over the years highlights the marginalisation and exploitation of poor women’s labour.
The payment to CHWs has been a major source of concern for planners. The CHWs have worked as volunteers and also as salaried workers in different experiments across the world. This article focused on the Mitanins of Chhattisgarh, who initially worked as volunteers, gaining acceptability as community representatives. The national-level launch of the NRHM brought in changes in the Mitanin programme, incentivising certain activities. The health department further pushed these activities as the department itself was assessed on those parameters. As a consequence, other important tasks of Mitanins found declining support from the health services and, instead of being a bridge between the public health facilities and the community, these women began to function as the lowest cadre of the health services, with minimal pay, no benefits and no security.
Since 2013, Mitanins have started getting incentives from the village health and sanitation committee instead of from the health department. This organisational shift in disbursement of payment will be fraught with new challenges and tensions for the Mitanins. A number of new activities have been added, such as, conducting cluster meetings, identifying cataract disease and promoting spacing methods, in order to provide Mitanins worthwhile incentives and a more meaningful income.
In practice, the incentive-based system still distances them from being recognised as workers of the health department. This has also led to the formation of ASHA unions in different parts of the country and demands regarding fixed pay, regularisation, a dress code and also other benefits. As incentives come from the health system, it gives officials greater power over the Mitanins, thereby dwarfing the ‘community aspect’ of the programme. Over the years, Mitanins have ended up as the last link in the health workforce. This has weakened their ability to represent the community, as they have increasingly got involved in meeting the targeted demands of the health services. Nor do they have any voice in the health system, further reducing their value. With a public health service that has not improved much over the years, and with poor interaction between patients and Mitanins, much remains to be done. It will be important to see how, in the long run, Mitanins continue to meet these challenges with little recognition of their work in women’s health, coupled with inadequate compensation.
Footnotes
Acknowledgements
The author acknowledges Professor Imrana Qadeer for guiding the study on Mitanins.