In a first, two community health workers from Nepal are participating in the ILO’s ongoing annual meeting Geneva, Switzerland. They aim to draw the world’s attention to their sustained struggle for rights and respect.

Basanti Maharjan and Gita Devi Thing, two Female Community Health Volunteers (FCHVs) from Nepal, have taken their fight for recognition, rights and respect to the ongoing UN International Labour Conference (ILC) in Geneva, Switzerland. FCHVs are Community Health Workers (CHWs) in Nepal, and like their sisters in India, parts of Pakistan, the Philippines, Thailand and parts of Africa, they are denied the right to wages, social security and job security.

The two women leaders have joined the delegation of global union federation, Public Services International, in the scheduled discussion on the care workforce. It is the first time the annual meeting of workers, governments and employers will discuss the shocking conditions of unpaid CHWs and comes after more than a decade of campaigns by PSI and its affiliates. 

Both women have lost family members to preventable health conditions and are committed to building stronger public health systems, but insist this must be done by respecting the primary health workers on the frontlines of healthcare delivery.

“Despite making sacrifices and doing our work earnestly, we are not treated as workers but as volunteers. This is unjust. We deserve dignity, respect, and fair compensation for the vital services we provide to our communities.” Thing asserts. 

“Lack of investment in public health systems has resulted in unfair treatment of CHWs. We face shortage of staff, lack of social and health security measures, and no or low remuneration. With the support of PSI we are fighting to change this,” says Maharjan. 

Denied recognition as workers

Kate Lappin, Asia Pacific Regional Secretary of Public Services International, the global union supporting the workers, says that these women are exploited because of their gender. “Why do we expect women to accept miniscule honorarium payments for critical public health work?” she asked. “It’s clearly because women’s care work is devalued and taken for granted,” she added. 

Lappin says the ILO meeting is a turning point for CHWs. “CHWs across Asia are organising and winning. It is because of this joint work that the world will finally discuss the exploitative conditions they work in. We expect the Conference to call on all governments to recognise CHWs as workers, pay them as public health workers and for the ILO to work with PSI to ensure these women enjoy their clear right to Decent Work,” she adds. 

Community Health Workers form the backbone of the national healthcare system across South Asia, parts of Southeast Asia and Africa. Yet they are consistently denied recognition as workers. The vast majority of CHWs are women – indeed, in some countries, this work is legally restricted to women, who are often recruited from rural, low-income and marginalised communities. The failure to recognise CHWs as workers stems from the gendered devaluation of care work as inherently women’s work. CHWs are deeply committed to serving their communities and improving livelihoods. Yet despite their vital role, they face numerous challenges, including payments (not wages) that are well below poverty levels, poor working conditions, inadequate training, and little or no access to social protection.

Understaffed and underpaid

There are more than two million Community Health Workers across parts of South Asia, Southeast Asia and Africa, who are delivering critical primary health care to local communities, yet denied recognition as workers. As a result, they are consistently deprived of regular, decent wages and social protection. In South Asia, the entire community health worker workforce is made up of women, often from marginalised backgrounds. Communities are dependent on the vital services that CHWs provide, including in relation to immunization, maternal and child health, primary health care and public health information services. The institutions that recruit and employ them (national or local government institutions or NGOs) define where, when and how these CHWs carry out their assigned tasks. While their status as workers is typically not recognized in law or practice, CHWs are in fact public health workers whose work as an essential bridge between the public health system and the community.

Often outnumbering physicians, nurses, and midwives combined, they grapple with myriad health challenges, including maternal and child health, sexual and reproductive health, mental health, communicable and non-communicable diseases and responding to public health emergencies and disasters. They have filled a gap caused by underfunding public health systems, particularly in rural and marginalised communities with scant formal healthcare infrastructure, supporting significant improvements in public health, including in maternal and child mortality.

The ILO Committee of Experts on the Application of Conventions and Recommendations, “recognises community health workers as an often-overlooked component of the health workforce, made up predominantly of women. They are often untrained or undertrained, understaffed and underpaid, or indeed unpaid, and are frequently recruited to compensate for shortages of health workers, particularly in rural areas and remote communities.”

Image: Public Services International