Over the last year, Frontline Workers (FLWs) such as Anganwadi Workers (AWWs), Accredited Social Health Activists (ASHAs), and Auxiliary Nurse Midwives (ANMs) have found themselves at the forefront of combating the pandemic. This is not surprising, as these three FLW roles have been the backbone of public healthcare and nutrition delivery in rural India even prior to the pandemic. But, even as their responsibilities have expanded during the pandemic, the nature of their challenges have simultaneously evolved. 

To understand the changing role of FLWs, we started documenting worker perspectives as part of the Inside Districts series in 2020. The insights from the interviews gave us a broad understanding of the prevailing situation. To dive deeper, we also conducted a quantitative and qualitative study with FLWs in two districts each of Himachal Pradesh and Rajasthan from November 2020-January 2021 (download the report for complete methodology) with the aim of unpacking the following: 

1. The evolving role of nutrition and health FLWs during the COVID-19 pandemic, including perspectives on their barriers and facilitators of performance. 
2. Insights on processes and best practices related to training, implementation, and supportive supervision, which can inform policymakers and functionaries in the short to medium term.

In this first part of a blog series, we will focus on some of the study’s findings. These relate to the duties performed by FLWs during and after the nationwide lockdown announced in March 2020, and the workload difficulties they faced. 

Evolving roles and responsibilities

With the onset of COVID-19, FLWs’ revised responsibilities included screening for COVID-19, contact tracing, communication of preventative measures to local communities, adapting nutrition-related programmes, and doorstep delivery of maternal and child health services. (A snapshot of their regular responsibilities is available below.)

Figure 1:

Majority of key services were provided, albeit at a lower scale

A directive was issued by the Ministry of Health and Family Welfare (MoHFW) in April 2020 to ensure the continued delivery of essential health services during the lockdown – including reproductive, maternal, newborn, and child health. Key services indeed continued in some form during the lockdown across both states, as per the FLWs we surveyed. 

These services included antenatal care (ANC), growth measurement, counselling of pregnant women and lactating mothers, and immunisation. FLWs largely performed only pandemic-related tasks until May.

However, the scale of most services reduced during the lockdown months (March to June 2020), with similar trends being reported by all three FLW roles. For instance, 50 per cent of FLWs in Rajasthan and 44 per cent in Himachal Pradesh reported that the distribution of supplements (such as ORS, Zinc, and Iron-Folic Acid tablets or syrups) took place at a lower frequency or scale as compared to the period before the pandemic. 

Download infographic on the reduction in the scale & frequency of services provided. 

Other services witnessed a slowdown as well. These were ANC, immunisation, distribution of family planning items, growth measurement, referrals for malnourished children, and pre-school activities for children. 

Graph 1:

These results were corroborated by country-wide trends from the Health Management Information System (HMIS), which indicated that there was a reduction in the coverage of various services across India during the lockdown. For example, the number of fully immunised children (9-11 months) stood at 46.6 lakh between April and June in 2020-21, approximately 11 lakh fewer than the number reported for the same period in 2019-20. 

Workload increased as regular services opened up

The study found that in December, most pandemic-related activities continued along with the recommencement of regular service delivery to operate at pre-pandemic scale, implying an increased workload for the FLWs. Even prior to the pandemic, FLWs reported feeling overburdened. We found that work increased by an additional three hours every day for 83 per cent of FLWs. 

A large part of the increase in workload could be attributed to the return of migrant workers to their hometowns. Ninety per cent of FLWs surveyed reported a rise in the number of people in their work area, and on average, each FLW had to manage 277 more people than before. Moreover, around 15 per cent of the FLWs reported having to serve more villages, which also meant travelling longer distances for work. This challenge was especially acute in Himachal Pradesh, where the terrain is mountainous, modes of public transportation difficult to come by, and road access to remote areas poor.

Importantly, FLWs also reported difficulties in providing other services due to their continuing COVID-19 related tasks. The situation was particularly difficult for AWWs, who faced a higher increase in the number of people served compared to ANMs and ASHAs. 

Table 1:

Motivation levels were not uniform

The increase in workload for the FLWs compromised their means to perform well due to the longer working hours, and some reported lowered motivation due to the lack of a work-life balance. Others continued working through the pandemic, feeling a strong sense of duty towards the communities they served.

The day never ends…I have had to go to houses at 7 pm because my supervisor told me to check for symptoms. My supervisor has a daily quota of 10 houses for survey. This is challenging, because I can only do surveys after 1 pm, before which I have to be at the Anganwadi Centre and do tasks like taking weights of pregnant women, teaching children, and immunising.

– AWW, Jaipur district, Rajasthan

But, even when facing these challenges (refer to Table 1), most FLWs did not reach out to anyone for resolution, which was likely due to the urgency of the pandemic and work pressures and the lack of regular grievance mechanisms. Of those that did reach out to their supervisors, only 10 per cent of FLWs were able to resolve their issue completely. For most, either there were partial solutions or no resolution at all. 

The study’s findings indicate that the nature of FLWs’ workload expanded during the COVID-19 pandemic – they were overworked, but soldiered on. FLWs had to be trained on new tasks and were also reoriented on conducting regular activities in the context of a pandemic. Fulfilling new responsibilities also necessitated the distribution of protective gear and an increase in remuneration by the government. 

In our next blog, we will discuss the extent to which FLWs were able to adjust to the new norms, and the quality of support they received from the government. 

This study was conducted through a research grant provided by Azim Premji University, as a part of their COVID-19 Research Funding Programme 2020.

Also Watch: