Blog 13 | HEaL Institute & IJME – Covid-19 Insights | July 16, 2020
Being at the frontline of COVID 19: Conversations with grassroots health care workers | Contributors
In this blog we bring you highlights of a webinar where health care workers (HCW) working at the grassroots took centre stage by coming on board as panellists. They shared their experiences of working during COVID 19. More than a hundred individuals from different backgrounds and areas of work, from around India and outside, participated in the webinar. The theme of the webinar and choice of panellists have roots in the Community of Practitioners on Accountability and Social Action in Health (COPASAH) international symposium, 2019.. Azim Premji University, Bangalore; Health, Ethics and Law Institute-Forum for Medical Ethics Society, Mumbai, Innovative Alliance for Public Health, India; Seher, and COPASAH, as co-organisers had conceived and curated a strand titled, ‘Healthcare workers and community: Forging alliances’.
The objectives were two-fold. (a) To locate them in the system characterized by power hierarchies.; (b) To appreciate the ongoing efforts and strategies of HCWs [including Auxiliary Nurse Midwives (ANMs), Accredited Social Health Activists (ASHAs) and other community-level health workers (CHWs)] while demanding accountability from the state and to provide HCWs with all the support needed to help deliver on their commitments to communities by building and maintaining trust based relationships with communities. The underlying philosophy is to enable HCWs to be the change agents, rather than mere service providers. This webinar is part of the ongoing work we have been pursuing in this space accountability with focus on HCWs.
Against this backdrop, the webinar aimed to have an open conversation with HCWs, including nursing professionals. The conversation was focused on key questions: How do grassroots HCWs prepare themselves to deliver on their commitments during this unprecedented pandemic and deal with these challenges? How have they been supported by the government in capacity building, protection and communication, reflecting the recognition of their role in the containment and other surveillance related activities during the pandemic alongside their routine non-Covid-19 related health care responsibilities?
The panellists included Ms Laxmi Kaurava facilitator for Accredited Social Health Activists (ASHAs) from Madhya Pradesh; Ms Kiran Beheriya, a Mitanin [‘woman friend’ in local language – a village level health worker] from Chhattisgarh; and nurses Mr Prakash Pandey and Mr Mansingh Jaat from Uttarakhand and New Delhi respectively along with Mr Kavi Kumar from Uttarakhand.
The conversation offered insights into their experiences working on the ground during the Covid-19 pandemic, challenges faced as a result of minimal support from the government. The webinar also highlighted the opportunities HCWs created for themselves to fulfil their commitments to communities by forging and strengthening collaborations amongst themselves in fighting the pandemic. The discussion highlighted accountability fault lines and lack of recognition by the government of their significant contribution to keep their communities safe and healthy during the pandemic.
“If we get scared, it will not work”: Personal preparedness for professional commitment
It was poignant to hear from the panelists about how they dealt with their own fears and anxiety about the likelihood of them contracting Covid-19 infection during their work. They also had to fight the stigma attached to Covid-19 (which stems from misinformation around it), and its implications on themselves and their personal and professional lives.
Kiran, a Mitanin who looks after 180 households in an urban hamlet shared:
“…Initially I was scared so was my family. They asked me not to go out as it has risks. But all of us including the mitanins, the members of the aarogya samitis, and the ANM had a meeting for a couple of hours. Our medical officer of the primary health centre also came to the meeting. We got a lot of information and realized that if we get scared, it will not work. I then convinced my family to let me work.. …”.
Health workers at other places too were found to have stayed away for months together to protect their family members. Health workers addressing their own fears have been critical in beating the spread of the pandemic rumours and misinformation within communities were adversely impacting their professional commitments and in turn the health and well-being of communities themselves.
The panelists mentioned that the fear translated in not trusting the health workers, suspecting the information shared about the disease, hesitating to respond to routine health services including immunisation, avoiding the use of hospitals/clinics or even ambulance for delivery services and in some case stigmatising them specifically in the urban areas. The panelists resorted to connect and engage with communities to respond to this situation. Several efforts were made to beat this fear, rumours and stigma by actively promoting the stories of those who have recovered, making persistent visits to the households and communicating about how to protect and prevent, demonstrating and/or using community radio platform to share adequate information about disease and measures of protection.
Strengthening the community connect has been the key as Laxmi articulated:
“… As a facilitator, it was important for me to ensure that the bonds between the villagers and the ASHAs remain strong. If they lose the trust during this difficult time, they will never be able to work for the health of the community. ….”.
The role of trust and support of the community was reinforced by other health workers too which was truly rewarding.
“Only if we are alive, we can fight”: Forging ties of collaboration and building on mutual strengths
Laxmi, an ASHA facilitators’ experiences brought forth the fault lines in the health system accountability. Despite repeated pleas to the government about adequate protection measures for the safety of ASHAs and other workers, and their families as well as the community members; she along with her colleagues were never provided adequate masks, sanitizers and hand gloves. Nor were they given any training on how to combat this novel pandemic. ASHAs are at a high risk as their work involves going door to door in the villages to collect information on movements of people, observing symptoms, communicating how to protect and prevent apart from addressing other routine health ailments. How did they respond then? Laxmi added:
“We have a network – ASHA Sahayogini Sangh (Network of ASHA facilitators) – and are connected on WhatsApp group. We were hearing so much about this illness being dangerous so we decided that we should keep up with the information. We decided to follow the WHO guidelines. … We sent each other links and also circulated in different state-level groups. … ”.
“Only if we are alive can we fight. Through our Sangh , we pooled in money to make masks ourselves to ensure adequate protection for our ASHAs. We also bought soaps and masks for the villagers.”
Newer expectations from communities during Covid-19: Response from and implications for CHWs
Disseminating information about safety measures to the communities raised their expectations with regard to accessing things like masks and sanitizers. Not able to access these and impracticality to practice physical distancing or quarantine led to their discontentment. This discontent was then directed against HCWs. Some of the community concerns panelists shared include:
“They asked us how they can buy masks and sanitizer when they are unable to buy food. …” (Kiran)
“Migrants have come back (to their places of origin) after several years and the house is not in a habitable condition. … So not being able to stay at home is a constraint and not a choice.”. (Laxmi)
In such situations, health workers have walked an extra mile to contextualise the health messages. For example, in the absence of masks, health workers have asked people to cover the nose and mouth with any clean cloth; if villagers must be out to work in the field [and hence staying home is not feasible], they have allowed them to be in the field but certainly encouraged them to work with their nose and mouth covered and to keep a soap to wash hands. Furthermore, they have taken additional responsibility to arrange either masks/soaps or even food and other essentials. Kiran shares:
“… All of us got together to buy things with our own money. We also used to go to the Nagar Nigam (Municipal Corporation) to get food for villagers by foot. …”.
Rising expectations has also had an impact on the mental health of the workers. The meagre financial incentives for the ASHA workers, continuous risk of contracting infection, working often under difficult conditions and isolation from the family have put these workers under tremendous stress. Mansingh, a clinical nurse shares the condition of nurses in the metropolis:
“This new routine of wearing the PPE kits, dealing with traveling in this situation, dealing with quarantine, availability of equipment, new guidelines rolling out every now and then all this together has an impact on their mental health.”.
The health workers’ experiences show how individual motivation, community trust and support, the role of networks and sangathans (organisations) is been critical in their COVID 19 fight so far. All of them reiterated that what is lacking is a distinct recognition of their contribution and necessary support by the Government to ensure their safety. One of them asked:
“…Aren’t we the frontline warriors?”.
Contributors: Arima Mishra (AM), Sunita VS Bandewar (SVSB) and Sandhya Gautam (SG) conceptualized and developed the blog.
Webinar organisers: AM, SVSB, SG and Santosh Mahindrakar conceptualized the webinar.
Acknowledgements: We are grateful to Sanjana Santosh, an independent public health researcher for rapporteuring conversations of the webinar and E Premdas and our other colleagues and friends for their support from COPASAH.
Blog Editor: Tejal Barai – Jaitly
Mishra, A., Bandewar, S., Gautam, S. (2020, July 15). Being at the frontline of COVID 19: Conversations with grassroots health care workers [Web log post]. Retrieved from https://fmesinstitute.org/blogs/