Why women serving as frontline health workers in India do not even get the minimum wage

Every weekday from 10.30 am to 3 pm, a family in Mumbai’s Dharavi slum hands over their 50 sq ft home to Rekha Bagle for a monthly rent of Rs 750. In this cramped space, Bagle runs the Shivashakti Chawl anganwadi, performing a long list of duties assigned to her under the Integrated Child Development Scheme, a central government programme to tackle malnutrition among vulnerable citizens.

She gives out nutritious food packets to infants, pregnant women and lactating mothers from the neighbourhood, maintains records of their health indicators, advises young mothers on nutrition and childcare, provides hot cooked meals to children under six and works as a pre-primary teacher for 25 to 30 of them. Once all the beneficiaries leave, Bagle and her helper, Hema Kadam, spend around two hours documenting the day’s work in a bundle of registers.

For this intense six-day week job, Bagle is paid just Rs 7,000 per month – Rs 3,000 mandated by the Centre and the rest offered as an incentive by the Maharashtra government. As the anganwadi helper, Kadam earns a total of Rs 3,500 a month.

Though they work for a government scheme, their payment is officially described as “honorarium”, not a salary.

This is a key reason why Bagle was unmoved by Prime Minister Narendra Modi’s September 11 announcement that his government will increase the honorarium for anganwadi workers, auxiliary nurse midwives and accredited social health activists from October.

According to Modi’s announcement, made with an eye on the 2019 General Election, the mandatory component of an anganwadi worker’s honorarium is being raised to Rs 4,500 from Rs 3,000. The pay for mini anganwadi workers (who manage smaller anganwadis singlehandedly in remote villages) will go up from Rs 2,200 to Rs 3,500, while anganwadi helpers will now get Rs 2,250 instead of Rs 1,500.

For each auxiliary nurse midwife and accredited social health activist, or ASHA – trained community health workers who help implement the National Rural Health Mission at the village level – the Centre is doubling the “routine incentives” they get for completing specific tasks. At present, ASHAs get Rs 200 for ensuring a hospital delivery for a pregnant woman and Rs 100 for getting a child immunised. They will now get double that amount.

The Modi government has called this a “landmark increase in remuneration” but for 28 lakh anganwadi workers and over 11 lakh ASHAs and auxiliary nurse midwives in the country, these honorarium revisions offer little comfort.

Many of these workers – almost all of them women – have spent years demanding recognition as government employees performing crucial full-time jobs as frontline health workers. At the Kisan Mazdoor Sangharsh rally in Delhi on September 5, lakhs of anganwadi workers and ASHAs demanded employee status and a minimum wage of at least Rs 18,000 a month.

By ignoring their key demands and revising their honorariums instead, the Centre has reiterated its view that these women implementing India’s health and nutrition goals at the grassroots level are merely honorary volunteers, not actual workers.

“We do not get paid enough for what we do and the revised honorariums will not help raise our incomes much,” said Bagle, an anganwadi worker for 12 years. “Why can’t the government just recognise us as proper workers? Why can’t they give us minimum wages?”

Plight of anganwadi workers

Though India’s 7th Pay Commission mandates a minimum monthly wage of Rs 18,000 for skilled workers, anganwadi workers have struggled for years to get even a little more than the paltry minimum honorarium of Rs 3,000.

Of this Rs 3,000, the Centre contributed 60% while state governments put in the rest. In response to protests by anganwadi worker unions over the years, some states offered incentives to increase the overall honorarium. Maharashtra, for instance, now pays anganwadi workers a total of Rs 7,000 a month. Kerala pays Rs 10,000, Telangana Rs 10,500 and Haryana recently raised the total honorarium to Rs 11,400 – the highest in the country. Uttar Pradesh is among the states paying the lowest honorarium, offering anganwadi workers just Rs 1,000 over and above the mandated Rs 3,000.

Anganwadi helpers typically get half the amount that anganwadi workers are paid, although they too work full-time, six days a week.

Now, even though the government has offered a 50%-60% pay hike for anganwadi workers and helpers, it amounts to an increase of barely Rs 750 to Rs 1,500 a month.

“Instead of this small pay hike, the government could have at least directed all states to pay anganwadi workers as much as Haryana is now paying them,” said AR Sindhu, general secretary of the All India Federation of Anganwadi Workers and Helpers, a union affiliated to the Communist Party of India (Marxist).

Conditional incentives for ASHA

The situation is worse for ASHAs, who work seven days a week, often at odd hours, travelling long distances to counsel families and connect women and children to primary healthcare centres. Yet, their payment is conditional on meeting specific targets for universal immunisation, reproductive and child health, sanitation and other programmes.

Typically, an ASHA gets Rs 1,000 or Rs 1,500 from the Centre for completing a set of eight different tasks under various health programmes. States add small incentives for other work they do, though this amount varies from state to state. “In Telangana, ASHAs can get up to Rs 6,000 as incentives but only if they do additional work for other government schemes,” said Ranjana Nirula, convener of the All India Coordination Committee of ASHA Workers. In Andhra Pradesh, said Nirula, ASHAs get a maximum of Rs 7,500, no matter how much additional work they are made to do. “ASHAs are trained workers,” she added. “By comparison, unskilled labourers in states like Kerala get Rs 600 a day for their work.”

Nirula pointed out that the revised honorariums will double incentives only for the eight or nine main tasks the Centre expects ASHAs to do. “On the ground, ASHAs are made to do at least 35 different tasks for which they either get some or no incentives,” she said.

Delayed payments and rations

Poor honorariums are not the only problem that anganwadi workers and ASHAs face. Across states, payment delays are common, forcing these frontline workers to make do without an income for between two and six months. In Mumbai’s Dharavi, for instance, Bagle has been getting her honorarium once in two months for several years.

To make matters worse, many states also delay funds for purchasing the ready-to-cook take-home rations that anganwadis distribute to vulnerable beneficiaries. “In parts of Uttar Pradesh, children have not been getting food supplies for six months at a stretch,” said Sindhu. “Some anganwadi workers are putting in their own money because officials tell them they will get paid for it later.”

In Bihar, Jharkhand, Chhattisgarh and Madhya Pradesh, around 70% of anganwadis are in similarly dire situations, said Sindhu.

In Maharashtra, Shubha Shamim observed the same problem. “Money for hot cooked meals had been pending for a year in many parts of the state, so we were paying from our own pocket,” said Shamim, state general secretary of the Centre of Indian Trade Unions. “Then in September, we finally got money for five months together. But even that has cleared the accounts only till March.”

Anganwadi workers and ASHAs often have to labour in poor working conditions, with the government making little effort to ensure their health or security. Since ASHAs assist pregnant women and help them get access to hospitals, they may have to attend to women in labour at odd hours and face harassment in the process, said Nirula.

In many places – especially in urban slums – anganwadis are forced to operate in unhygienic or cramped conditions. “We have a gutter right by the doorstep of the house where we run our anganwadi,” said Bagle. “Children sometimes fall in the gutter and get infections. The government won’t provide any better place for our anganwadi.”

‘Gender is a major factor’

The refusal to recognise anganwadi workers, ASHAs and auxiliary nurse midwives as government employees is also a gendered problem. “Gender is a major factor here,” said Nirula. “All the work these women do is related to care, nutrition and health. So women are told it is an extension of their housework.”

This is despite the fact that ASHAs and auxiliary nurse midwives are trained to deal with primary health problems and, hence, ought to be recognised as skilled workers.

Shamim put it more bluntly. “Because we are women, they want to get us to work more for the least amount of money,” she said. “In addition to their daily work, anganwadi workers are made to work on schemes such as Swachhata Abhiyan. They have even made some of us survey dogs and pigs in the village, and we get no extra money for this. Sometimes workers refuse, but the government makes them do it anyway.”

Scroll.in contacted officials at the Women and Child Development Ministry and the Ministry of Health and Family Welfare for comment, but did not receive a response. This story will be updated if and when they do.