Workplace mental health
Burnout on the frontlines
What have we done to the biggest cadre of health workers in India?
She is a rural health worker. She walks on foot all day in her village, often a daily walk of 4 or 5 kilometers. She checks on the health of people, door-to-door, especially pregnant women, infants and young children. She refers cases that need a check-up at the nearest health centre, including deliveries. She gets a few hundred rupees a month for this work, but these incentives are rarely paid on time. She would cover 25–30 homes each day, often more. She is usually a married woman, with children, in-laws, and a husband. So, if she misses a day due to domestic chores (or the biting heat or cold), then she piles up work, the sort of backlog that she would not want. She has to update records of the people she checked, on paper, as the kind of digitization that we enjoy has not reached her village. She gets a salary of ~2000 rupees on average, for door-to-door work, but that varies from state to state in India, and is often delayed, sometimes for months.
Now, let’s imagine the above with additional COVID-19 testing and vaccination duties.
Who is she? She belongs to a cadre of more than 1 million rural frontline health workers in India, called the ‘ASHA’ workers.
Why was she created?
The policy on paper
In 2005, we brought her into the system because there were too few or no doctors at the village-level — pretty much unchanged even today. So, we needed someone to act as a ‘bridge’ between families and their nearest health centres, so that they could seek care and receive services. And for that, we needed someone to generate awareness on health issues, conduct basic check-ups (e.g., temperature or weight) and offer essential provisions (e.g., iron tablets, ORS, or condoms) door-to-door, across villages. We aptly titled her ‘Accredited Social Health Activist’.
The guidelines of the National Rural Health Mission, which introduced the ASHA worker in India, categorize her as an ‘honorary volunteer’ and claim that her work would not disrupt her normal means of livelihood (assuming that there is any time left with her for more formal jobs). According to this work profile, ASHAs are supposed to work for 2–3 hours a day for 4 days a week.
Given the definition of a volunteer, the central or state governments do not have a legal duty to pay minimum wages to ASHAs. The fact that we have not yet started to pay her a salary anywhere close to 18,000 rupees a month (the norm for central government ‘employees’), even though she easily works for 8 hours a day and more than 40 hours a week (especially in the pandemic time), shows our sheer unwillingness to invest in the biggest health workforce of India.
So, why does she continue, overworked and underpaid?
Dependency and desperation.
The girl in the picture should be enough to answer that question.
ASHA workers have families to feed, children to put in schools, and elderly to support. An average family of five, and a monthly income of 3000 rupees is grossly inadequate, per head. The pandemic, more so, has disrupted several local businesses and jobs, or reduced spending by customers, prompting the business to either shut down or employ smaller cadres (e.g., factory labor).
But it’s not just the money. ASHAs work, knowing that it is a form of service, with the consciousness that their work would be respected in their village, as one of them quotes:
“My mother used to work as an Anganwadi worker [another cadre] in the health department. I would often help her out with her work and was inspired by her to come into this line of work.”
But, where’s the respect?
Burnout is not just a result of being overworked and underpaid.
It can be assumed that an ASHA worker serving a village that is usually far off from the ‘nearest’ adequately staffed, equipped health centre (such as a district hospital, and traveling to such places would mean losing a day’s income for most families) would naturally evoke respect in the community, but that’s not the case. The disadvantage begins with her gender.
My first ever public health research endeavor in 2011 involved interviews with ASHAs in rural Kanpur (Uttar Pradesh, India) to understand their problems in counseling male clients on the need to adopt ‘vasectomy’ as a harmless, bloodless procedure for fertility control, instead of the more complicated tubectomy in women. The fact that vasectomy was highly stigmatized among men (thanks to the scars of the reckless vasectomy drives undertaken during the nationwide Emergency, 1975) was only a part of their challenge. The more basic challenge was the mere communication of something like vasectomy to their ‘brothers’ and the hostility it evoked from their wives and families, often jeopardizing the reputation she had built thus far in the village, thanks to her more ‘mainstream’ work (e.g., vaccinations and the like). Naturally, ASHA workers felt tremendous pressure of meeting their vasectomy ‘targets’ in order to receive their incentives.
ASHA workers have also pointed to their presence being a source of irritation to the community, as they cannot actually treat a disease (and are not authorized to) but only provide information.
Let’s say someone has a fever, or if someone is experiencing any kind of pain, we can only give them information about medicine but not the medicine. This limitation irks us a lot. The government has not provided any actual resources for us to be able to help them. We only go there as providers of information and collectors of data — which, of course, frustrates the community.
Further, COVID-19 has brought additional work hours for ASHA workers, with additional risks of infection and additional disrespect, such as stigmatization in case of ASHAs who were tested positive:
“My neighbors stayed away from me and my daughter. Even at work, I faced stigma. Most people want to avoid you, even if you have been cured.”
ASHAs have reported threats, abuse or instances of violence, especially in the aftermath of the pandemic, from their peers, beneficiaries, and especially from family members:
‘I returned home at 10:30pm at night. There were arguments as to why I came home late. He used abusive words and foul language and he started to shout saying, ‘What kind of bloody meeting did you have?’’
The most basic level of dignity we can offer to a frontline worker battling a rampant virus on a daily basis is adequate protective gear, but inadequate masks and reliance on home-made cloth masks have been prevalent among ASHAs. As quoted by an ASHA below, the attitude towards a ‘volunteer’ cadre is crystal clear -
We have been given only 6 masks and one 500 ml sanitizer bottle since the pandemic began. Whatever little they have provided was also made possible when our union took up the fight with the public health officials.
Unsurprisingly, as high as 109 ASHA workers across India have succumbed to COVID-19 infection.
Do we understand the nature of their burnout?
No, we have only looked at it from an ‘incentive’ lens.
Even public health researchers (like me) and large-scale research projects have been unfair to ASHAs.
A review of 10 years of published studies on ASHA workers quoted the following:
“The most extensively researched health systems topics were ASHA performance, training and capacity-building, with very little research done on program financing and reporting, ASHA grievance redressal or peer communication.”
Looking at the quote, one wonders at our emphatic push to train ASHA workers on a range of services, plausibly because they are available, living in the village, closest to the communities and ‘volunteers’. It’s as if we have not stopped packing their work profile with as many services as possible, which explains the bulk of studies under the ‘training and capacity-building’ ambit.
Even when we recommend studies on ‘grievance redressal’, we view their burnout as a mere symptom, from our vantage-point, labeling it as a ‘grievance’ that needs some ‘redressal’.
Perhaps we do not want to dive deeper into their experience of burnout, the ways they could be responding to work burden, low pay, and more so, the performance pressure, the pressures of community norms, the gender disadvantage, the stigmatization, the lack of safety, and the violence.
How do they internalize these experiences?
Whom do they talk to (and what do these conversations entail)?
How do they emotionally cope with these challenges on a daily basis?
How can they be made more resilient?
Can they be enabled to cope in ways that are possible and feasible, till the time their structural work conditions (hopefully) get better?
Redefining Workplace Mental Health
Does the massive cadre of ASHAs even have a ‘workplace’?
It felt strange to introduce the kicker titled ‘workplace mental health’ for this blog.
ASHA workers clearly do not have a workplace and it would be incorrect, unethical and insulting to categorize them as workplace employees for any sort of workplace mental health interventions, when on the other hand, we do not even recognize them as employees on policy documents.
That said, we must also recognize that research, conversations in the media, and the buzz around workplace mental health is from an urban, privileged lens.
But ASHA workers actually do have a workplace, like all workers do.
It’s an unstructured unpredictable workplace. It’s a demanding, tiring and demoralizing workplace, with little avenues for addressing an individual’s burnout.
We all, in our cities, address our work stress by learning to deal with it, finding ways and means, talking to supervisors, having social outings with colleagues on a periodic basis, talking to colleagues, reading, and finding time for things that we love.
Strategies to improve ‘workplace wellness’ for ASHA workers could be different from the above — and although it merits a dedicated blog, it must be said that these strategies should not be extensions of urbanized workplace wellness programs. ASHAs are rural, traditional, and burdened from various facets of their routine life and strategies need to account for the dynamics of their many relationships.
To conclude, the mental health of the largest health workforce in India has thus far suffered from a policy neglect, a programmatic omission, and a myopic research lens. It has been a suffering for far too long, given that the cadre came into existence in 2005.
Working towards improving their burnout and mental health is as crucial as the health of the families they look after.
