Compensating COVID Deaths: A New Look at the Welfare of Essential yet Undervalued Community Health Workers | Chemmalar. S

by Chemmalar. S *

Abstract

Indispensability of health workers has deeply entrenched during the global pandemic situation which amplified the demand for their service to tide over the precarious condition. Realizing their moral imperative towards the society, health workers have put their own life in peril towards safeguarding the humanity. The clueless situation has raised the prominence of preserving the workforce of medical care to tide over the condition. Given the current pandemic, the health workers continue to serve society with minimal payments and social security. The unprecedented event requires much more than mere appreciation to end their social and financial hardship. The pandemic is not discriminatory in itself, but it affects medical health workers differently. The paper comprehends the effects of COVID-19 on medical health workers with specific reference to community health workers whose incentives are accessed based on their task or activity. This article addresses the Indian government’s response in protecting the welfare of the health workers and their families in the face of the Covid-19 issue, as well as, will inform the significance of providing differential social security to the Health workers.

Key Words: Health workers, social security, COVID -19, community health workers

Who are health workers? 

World Health Organisation (WHO) report defines ‘health workers’ as “all people engaged in actions whose primary intent is to enhance health” [1]. In simple terms, ‘health Workers’ can be termed as “people who has to report to the workplace in the face of unknown threats and whose work could not be fulfilled with distance mode”. While mentioning the concept of Health workers, it is pertinent to point out the correlated term — ‘Health industry’. ‘Health industry’ often known as the ‘medical industry’, “is an industry that delivers goods and services to individuals in need of curative, preventative, rehabilitative, or palliative care”. It is composed of doctors, nurses, pharmacists, hospitals, and other components of the health-care system. Health industry is one of the vital and fastest-growing industries.

According to the WHO estimate, “the global demand for health care personnel will increase to 80 million health workers and economic growth will create the greatest increase in demand for health personnel across the globe by 2030”. WHO maintains a National Health Workforce Accounts Data Portal composed of compiled data on workforce Data on the health workforce with the intent to promote Universal Health Coverage, to achieve the Sustainable Development Goals, and other health goals. The data are extracted from national reporting which were then processed and stored in the database. It serves as the supplement source for national census, labour force surveys, and major administrative national and regional sources. The portal maintains countrywide profile on health workforce and the below given chart is the data on health force in India as updated in July 2019.

Table 1: WHO NHWA Platform — July 2019, National Health Workforce Accounts Data Portal

Indian Scenario of Health Workers

Among frontline workers, health workers are more vulnerable and have been affected by Covid-19, as they take health services directly to communities. Not only health workers were at high risk of infection, but many have regrettably died in the line of duty across their country. They also had to deal with the concern of contagion and passing the illness to their family members [2]. As of 2020, study by Amnesty International revealed that the death of health workers due to COVID — 19 has reached 7,000 across the globe. Mexico has recorded the highest death rate of 1,320 health workers followed by USA and UK which recorded 1,077 and 649 deaths respectively. While according to the report, India is placed in sixth rank with 573 deaths. The data by the Amnesty International on reported Covid deaths of health workers in India was in accordance to the data provided by Indian Medical Association as updated on 30 August, 2020. The report further states that Maharashtra accounts for over half of the health workers with 292 deaths of health worker [3].

It is pertinent to note that women are predominant workers in the health care industry, since they account for over 70% of the health-care workers. While the estimate in industrialized countries indicates that women make up 80% of the health workforce. Undoubtedly, Women are driving the health response and persevered despite difficult working conditions, thus, placing them at higher risk of infection [4]. The proportion of women as Nurses and midwives account for nearly 50% of global health workforce. The World Health Organization forecasts that the world will require 9,000,000 nurses and midwives by 2030 to achieve Sustainable Development Goal 3 on health and well-being. In the current context, health personnels’ working situations, particularly those dealing with COVID 19 patients, have been jeopardised. Long hours in intensive care units, a lack of personal protective equipment, and understaffed and resource-constrained environments, combined with high levels of emotional stress, expose health workers to increased risks of infection and transmission, particularly in low and under-resourced countries.

 As per Ministry of Health and Family Welfare, “in India 10.61 lakh accredited social health activist (ASHAs) is engaged in rural and urban areas under the National Health Mission (NHM)” [5]. The Government of India established the certified social health activist (ASHA) programme in 2006 with the purpose of connecting marginalised populations to the health-care system. ASHAs operate at the ground level to put any government health scheme into action. Their daily duties included checking on babies, pregnant women, and those who were at risk of disease. On a regular basis, they also distribute tablets such as iron deficiency tables. The current pandemic crisis has enlarged their job to keep an eye on covid-19 sighs among individuals and to spread preventive measures to the communities they visit [6]. Similarly, 2.6 million Anganwadi workers (AWWs), and an entire cadre of Auxiliary Nurse Midwives (ANMs) have been at the vanguard of the Covid-19 response system. For decades, the three groups of female community health workers have been working to improve primary health care outreach and community nutrition initiatives across the country. Despite the fact that their job is critical to India’s health-care system, they are frequently underpaid and underappreciated. During the pandemic, all three cadres reported feeling alienated and unappreciated for the disproportionate weight they bear in India’s war against Covid-19 without enough remuneration, personal safety, or state support. The unpaid, devalued, and invisible labour of India’s community healthcare workforce was critical to the country’s pandemic response.

Anganwadi personnel are responsible for a variety of tasks, including performing health syndromic surveys and keeping records of the results in collaboration with health care providers. ASHA personnel do door-to-door visits in villages to raise public awareness about various health conditions. Unlike Anganwadi and ASHA employees, auxiliary nurse midwives fulfil supervisory duties. ASHA employees have been involved in the contract tracing of suspected Covid-19 patients across all states by compiling extensive travel and contact histories. In the early months of the lockdown, they were involved in listing details of travel, contact individuals of every person entering the hamlet, particularly in the context of migrant returnees and travellers from overseas. Working within containment zones without proper facilities put ASHA workers’ lives in jeopardy in numerous states. Several ASHA workers have died in Bihar, Madhya Pradesh, Delhi, Assam, and Jharkhand, either as a result of Covid-19 infection or misfortunes such as traffic accidents and tiredness while doing their healthcare tasks. The study states that the family members of the deceased Workers have undergone hard times in getting the Insurance benefits [7].

On-Duty Deaths and social Security of Health workers in India

The government of India has submitted its report to the Lok Sabha on death toll of health workers. The report states that, as on 2nd February, 2021, 174 physicians, 116 nurses, and 199 healthcare workers had died in the country as a result of COVID-19. The report submitted by the government has cited the relevant data from states acquired through an insurance scheme. According to Rajya Sabha 123rd Report of 2020, 573 health-care personnel have died, with 364 of them being doctors. The report also indicated that total of 87000 workers are likely to be infected with the virus. The However, as per Indian Medical Association, 1492 medicine doctors have sacrificed their lives in the Covid-19 pandemic as on October, 2021. Among total number of deaths, the maximum of 128 doctors lost their lives in Delhi and 115 doctors died in Bihar [8].

Considering the safety and social security of the health workers, Government of India has initiated insurance scheme for Health workers combating COVID-19 named “Pradhan Mantri Garib Kalyan Package (PMGKP)”. This insurance scheme has been introduced for all health workers including ASHAs for providing insurance cover of Rs. 50 lakhs for on-duty death relating to Covid — 19. The scheme is active with effect from 3rd March, 2020 and implemented through the Insurance policy from New India Assurance Company (NIACL). Nonetheless, States and other stakeholders have criticized that the processing of insurance claims is prolonged. Again, in order to overcome the issue, the government has delegated the power of processing the claims to the State Government, where District collector is empowered to certify the claim which is then approved and settled by the insurance company [9].

The 3As - ASHAs, AWWs, and ANMs are the groups consist of women community workers who work at grassroots level fall within the ambit of two ministries, i.e., the Ministry of Health and Family Welfare (MoHFW) and the Ministry of Women and Child Development (MoWCD) [10]. MoHFW has ascertained that ASHAs do not fall under the Code on Social Security and the Code of Wages, 2020, since they are volunteers envisaged to be community health service. Hence, they are entitled to task/activity based incentives and cannot claim the benefit under social security schemes on par with the regular employees.

In this respect, ministry has requested the states to pay the incentive of Rs. 2000/- to ASHAs during COVID-19 Pandemic and additional incentive of Rs.1000/- per month for those ASHAs who are engaged in COVID-19 related work using the resources of “COVID-19 Health System Preparedness and Emergency Response Package” from January, 2020. Under the scheme, government has grated Rs. 1113.21 crore and Rs. 8147.28 crore to States/UTs as Grant-in-aid to state for facilitating the scheme. States/UTs were also asked to continue to pay other task based incentives to ASHAs such as Janani Suraksha Yojana (JSY), Home Based Newborn Care (HBNC), etc., as per National/State norms during the course of this pandemic period as per the activities undertaken by them.

The MoHFW has reiterated the following benefits for ASHA workers under the schemes-

• Pradhan Mantri Jeevan JyotiBeemaYojana (PMJJBY) - provides the benefit of Rs 2,00,000 for death of the insured, and the premium of Rs.330 is contributed by Government of India.
• Pradhan Mantri Suraksha BeemaYojana — provides 2,00,000 for accidental death or permanent disability and 1,00,000 for partial disability for which the Government contributes Rs.12 as annual premium
• (PMSBY) and Pradhan MantriShram Yogi MaanDhan (PM-SYM) — provides pension of Rs. 3000 on monthly basis on reaching the age of 60 Years. The premium contribution is shared by for government and beneficiary equally.

According to Ministry of Health and Family Welfare, till March, 2021, 8,78,071 community workers group including ASHAs have received additional COVID-19 and 43 claims have been paid for to ASHAs under Pradhan MantriGaribKalyan (PMGK) Package till June, 2021. Notably, as per the record of MoHFW no delay has been reported in payment of benefits by States and UTs [11].

Issues and concerns

Concerns vis-à-vis safety and welfare of health workers have been raised by various groups. Hundreds of thousands of community health workers (ASHA workers) went on strike in August to demand proper personal protective equipment (PPE), higher pay, and reasonable and favourable working conditions [12]. There has been a lot of conflicting information on total number of Covid related deaths. According to a BBC News survey, the government lacks consolidated data and does not keep occupation-specific census and death statistics [13].

The Indian Medical Association (IMA) has made a strong statement that “all doctors who have given their life in the fight against this pandemic to be honoured equally to Indian military martyrs and suitably recognized”. IMA stressed on providing government employment to the surviving spouse or dependent based on their qualifications.

Conclusion 

Health-care employees are the foundation of every health-care system. To secure the family and their future, social support to spouses and kin is the need of the hour. For instance, the state government of west Bengal has galvanized the state machinery and mobilized all resources at its disposal to combat the situation arising due to outbreak of covid — 19. It is evident from the recently designed special compassionate appointment scheme providing appointment to the kin of essential and frontline workers died due to covid - 19.

The scheme is based on two attributes — (1) death due to covid-19 (2) permanent incapacitation due to covid-19. As the title of the scheme indicates, it is really special, since it encompasses not only the permanent government servants but also employees working on temporary basis. According to para 2(A) of the scheme, apart from state government employees, rural and urban local bodies, public undertakings, Statutory Bodies or any Grant-in-Aid institutions were also given benefit. Para 2(B) take account of all frontline workers like ASHA workers, Anganwadi workers, civic police volunteers, multipurpose health workers, contractual and part-time medical personnel including nurses, sanitary workers, people engaged in laundry diet and drug management. The need of the hour is for each state to develop a particular system to solve the current situation, similar to West Bengal’s compassionate appointment scheme, to better address the challenges encountered by frontline workers. In this regard, it is the Central government’s responsibility to offer adequate instruction to the state government and its agencies.

* (Author: Chemmalar. S, Research Scholar, SRM School of Law, SRM Institute of Science and Technology, Chennai)