October 7 is World Day for Decent Work with a focus this year on “investing in the care economy.” Whether providing preventative health information, yoga classes or support in navigating official paperwork, community health workers spend their long days delivering invaluable benefits and care to members of the Self-Employed Women’s Association (SEWA). These women are part of the SEWA Social Security Team's Shakti Kendras (empowerment centres), operating across several Indian states.

This article is excerpted from a Workers’ Lives essay, which offers an intimate look at those who work in the Shakti Kendras, the wide range of services they provide in a challenging policy environment, and what they gain in return.

Savitaben has come a long way since she arrived in the village [in her local area of Jalalpur in the state of Gujarat, India] as a newlywed and, in 1993, began working with SEWA. “I’ve developed my confidence,” the community health worker says.

Since then, the centres have been replicated throughout India where SEWA operates, serving poor women informal workers who are often street vendors, home-based workers, waste pickers and agricultural workers.

Savitaben is part of a community of supervisors, volunteers and community health workers (CHWs) who run one of SEWA’s innovative Shakti Kendra or empowerment centres. SEWA, a union of almost two-million informally employed women workers in India, opened the first of these centres  in Delhi and Madhya Pradesh in 2007. In 2015 SEWA’s Social Security Team established the Shakti Kendra model in Gujarat, incorporating innovative best practices that extend social protections to informal workers.

Since then, the centres have been replicated throughout India where SEWA operates, serving poor women informal workers who are often street vendors, home-based workers, waste pickers and agricultural workers. Today there are 23 centres operating in several Indian states, including also Uttarakhand, Rajasthan, Bihar, West Bengal and Jharkhand, among others.

Finally, we arrive at the house where the training is happening. Inside, it is mercifully cool and shady after the hot walk. Women start trickling in wearing their colourful saris until eventually, about 20 members have gathered. Most are agricultural workers who earn about Rs200 a day.

Today’s training is on breast cancer, self-diagnosis and symptoms, and will last for about 35-40 minutes. Savitaben takes the register first: name, age, occupation. This helps to identify the members who attend, and which topics are relevant to which members. Then she introduces herself and explains the purpose of the training.

These educational sessions form an important component of the Shakti Kendras’ work, together with empowering SEWA members and the local community to access government social security, health, and nutrition programmes that have a direct bearing on their health and wellbeing.

To teach the women how to do a breast self-examination, she brings out posters with a little Gujarati text and a lot of pictures to show. Colourful posters such as these, full of explanatory images, are used to facilitate the centre’s intensive and innovative health education.

These educational sessions form an important component of the Shakti Kendras’ work, together with empowering SEWA members and the local community to access government social security, health, and nutrition programmes that have a direct bearing on their health and wellbeing. Members receive information and advice on state benefits that members are entitled to, how to obtain the necessary documentation to apply for these, and which government departments offer what services. They also receive support in navigating the often-complex procedures and entitlement system.

A central hub for activities

Previously, SEWA’s CHWs went door-to-door to deliver health information and education; now, the Shakti Kendras operate from a central location in the community, acting as a hub or nodal point for activities and information and providing a base for community outreach such as trainings, exhibitions and camps. The aim is to provide access to comprehensive and integrated health and social services in a space where people know they can come.

In some of the rural areas, SEWA has negotiated with the local government, and the Shakti Kendra has been set up in the village community centre. In urban areas, space is normally rented, or a centre might share space with government-sponsored Integrated Child Development Scheme (ICDS). The central location operates during convenient hours to meet informal workers’ needs, which is important in ensuring the centres are successful.

The aim is to provide access to comprehensive and integrated health and social services in a space where people know they can come.

“[H]aving this physical space with chairs and tables, it’s given me more recognition amongst the village members,” Savitaben notes, adding that they see her as a person who sits in the government hall and can help them get things from government. “Earlier...I was recognised as a person who gives information, but not much else.”

The Shakti Kendras have become a meeting place for local government representatives and the community members as well. Local elected leader or village headman take advantage of the convenience of the centres’ locations to address local issues and have dialogues with the community. Such meetings are facilitated by the CHWs, who act as the link between the two.

Shakti Kendra services

To support their mandate of health promotion and access to social services and security, the centres offer a range of services to members. These include yoga classes and access to affordable medications and ayurvedic (natural, preventative) treatments, together with health assessments, diet and nutrition camps—from where members can receive referrals to local state health services. Health and nutrition exhibitions and demonstrations are also offered. The focus of these is primarily on non-communicable diseases, tuberculosis (TB) and sanitation.

The Shakti Kendras create a communication channel between government and the grassroots, facilitating direct access to the state services.

More recently, centres have started to tackle mental health as well as Occupational Health and Safety (OHS) concerns. To keep members involved and interested, the CHWs innovate: for example, by bringing a nutritionist to the diabetes camps to give advice, or by inviting their members to judge food competitions as a way in which to provide education on micronutrients.

Focusing on collaboration and dialogue

In addition to providing the information that people need to access the entitlement system, CHWs like Savitaben also guide and support people throughout this process. The Shakti Kendras create a communication channel between government and the grassroots, facilitating direct access to the state services. They give people the space and confidence to speak out and be heard.

When a new Shakti Kendra is established, the CHWs and their supervisors will map out both available government services, as well as conduct a survey of community needs in relation to health and social services. “We need to know what issues the local community faces, and what their needs are,” Dhanguariben says.

Regular engagement with government workers has changed perceptions of the accessibility and the functionality of public health care and social services from the side of the workers, who have come to feel more confident about accessing and navigating the system.

“Our team goes to all the government departments to collect information—to see what they do, understand what services are on offer from each department, where to get forms, where to submit them, and identify key officials in the system. In doing this, we can then provide members with up to date and clear information,” Yasmeenben, a Shakti Kendra Team Leader, explains.

Enhancing confidence for CHWs and members

Regular engagement with government workers has changed perceptions of the accessibility and the functionality of public health care and social services from the side of the workers, who have come to feel more confident about accessing and navigating the system. “I can say that I have seen a change in the members—they are starting to seek healthcare,” Savitaben tells us. “Earlier we would have to go with them, but now...there are even members who are able to approach government officials on their own.”

Better access and better care

For Mukthaben, a glaucoma sufferer who runs a garment business in Rajiv Nagar, Ahmedabad, this increased sense of accessibility has meant better diagnosis and more affordable medication. “Most members never used to go to government health facilities, but now we go because we realized that it's low cost and for major issues, it’s much more affordable to go to the government hospitals,” she says. “I went from private practitioner to private practitioner, trying to sort out this glaucoma and they couldn’t help. I’d heard from people that government services are rubbish, but after going to one I’ve realised this isn’t always true. They might not be perfect, but they’re a lot more affordable.”

“I can say that I have seen a change in the members—they are starting to seek healthcare,” Savitaben tells us. “Earlier we would have to go with them, but now...there are even members who are able to approach government officials on their own.”

This interaction has changed SEWA’s relationship with the public health care sector, as well as the sector’s response and treatment of its clients. Pannaben, who works with many street vendors suffering from hypertension and diabetes, notes, “Earlier our members would go for iron tests and so on and they weren’t given very good treatment. There was a sort of standoff: we are government, and they are SEWA—but now there is a change in attitude of the staff and even the aanganwadi (government child care) workers. They are more keen to cooperate.”

This ultimately means more effective programme delivery on the part of government officials, and better service provision.

Moreover, the Shakti Kendras have had an important impact on the CHWs themselves. Savitaben observes that CHWs such as herself have learned how to make “links to higher authorities” and understand the workings of public systems, giving them greater confidence.

Dhangauriben agrees. “I used to think that if I have to meet a government official—how would I do that? What would I do? All of those questions were going through my head. But now I have the confidence to approach
the officials.”

To read the full story of SEWA’s community health workers, download the full Workers’ Lives publication.