Opinion India’s healthcare system is leaning too heavily on volunteers and contractual workers for essential services

ASHAs were introduced as part of the National Rural Health Mission in 2005, and their primary responsibility is to create awareness and mobilise potential beneficiaries to the health facilities. A new cadre of CHOs was initiated in 2018 to expand the services available through Health and Wellness Centres. They are dentists, nurses, or AYUSH practitioners recruited on a contractual basis who undergo training, and their remuneration is a mix of fixed payment and incentives.

ASHAs and AWWs are not healthcare providers. Both must have passed at least Class 10, come from the same community, and cover about 1,000 people or 200 households. Both are “link” workers — they connect the healthcare system to the community and provide the last-mile connectivity.

A volunteer approach was adopted due to poor experience with regular workers who had previously failed to ensure service delivery. Both are expected to work part-time for up to four hours a day. AWWs are given an honorarium, while ASHAs are paid per unit of work done as incentives. ASHAs are also expected to be available for any emergencies such as a delivery or a sick newborn, or to accompany a patient to a healthcare facility. On average, ASHAs earn Rs 5,000-10,000 per month and AWWs around Rs 12,000, varying by state.

ASHAs’ work during the Covid pandemic was globally recognised. In my interactions with ASHAs across India, I see them as a motivated group of people who feel a sense of pride in their work. They have now become critical cogs in the healthcare system’s wheel, which cannot run without them.

Over time, both these cadres have been entrusted with additional responsibilities that were not part of their original remit. These include population enumeration, NCD (Non-Communicable Disease) screening, and the provision of palliative care, among others. The system finds it easier to assign such work to these cadres and incentivise them, rather than compel an unwilling regular staff. This has increased their working hours beyond the original four, though with some remuneration.

Both ASHAs and AWWs, however, nurse a long list of grievances. These include increasing workload, inadequate safety and protection, and, most importantly, lack of appropriate and timely remuneration. Continued neglect of their issues has led to ASHAs forming unions, and strikes are now common in many states. Anganwadi workers also have unions and have been demanding regularisation. Courts have generally acted in their favour and have tried to extend to them the benefits of government employees, such as leave. However, the government maintains that they are “volunteers” and cannot be treated as government employees, though it has extended health insurance coverage to them.

The regularisation of these workers would not only result in a huge salary payout — given that they number more than a million each — but would also raise issues of promotion. No promotional avenues were envisaged for these volunteers. Regularisation and promotions would question the very basis and rationale for which these cadres were created in the first place. Though recently introduced, CHOs face many of the same problems as these cadres, and their promotional avenues are also not well defined.

Another healthcare workforce challenge is the number of vacancies in sanctioned posts. It is estimated that about 10-15 per cent of ANM (Auxiliary Nurse Midwife) and 20-25 per cent of doctors’ posts are lying vacant. These posts are now often filled through contractual appointments. The move towards contractual staff has largely been due to lower financial implications (lower salary, no pension) and administrative efficiency (avoiding delays and corruption in recruitment).

These examples call into question our approach to the public healthcare workforce by both the Centre and state governments. Many centrally funded schemes, such as those for CHOs, have been designed to bypass the states’ poor motivation to recruit regular staff. Most officials in the health ministry are aware of these challenges, but there are no easy answers. We need to bite this bullet and address some fundamental issues related to the mode of recruitment, the role of incentives, and the cadre structure of our healthcare workers. While contractual and volunteer-based staff do have a role, the system is currently leaning too heavily on them for the provision of essential services. A better balance needs to be struck.

The writer is a Professor at the Centre for Community Medicine at the All India Institute of Medical Sciences, New Delhi. Views are personal