According to SEWA's experience Social Security for self-employed women workers includes healthcare, childcare, insurance and housing.

SEWA’s experience of organizing social security services for women workers has shown that it should be contributory (i.e. with contributions from workers, employees, government and others), to be viable and effective. These services should be need and demand-based.

 

Healthcare

SEWA first became actively involved in the public health field in the early 1970s through health education and provision of maternity benefits. In the early 1980s SEWA negotiated with the Government of India (GOI) for helping to distribute maternity benefits (ghee, a dairy product similar to butter, was provided in kind) to poor women. Today, the SEWA Health Team provides a wide range or primary health care services, but the main thrust is to provide simple, life-saving health information with a focus on disease prevention and promotion of well-being. Other important goals have been: (1) to build capacity among local women, especially traditional midwives (dais), so that they become the barefoot doctors of their communities; and (2) to provide services to the very poor, particularly those living in areas not otherwise served by government facilities or non-government organizations (NGOs)

Providing Sustainable Health Care Services Through Women’s Health Co-operative

Background :

The Self Employed Women’s Association (SEWA) is a trade union of seven lakh women workers engaged in the informal economy in India out of which five lakh are from Gujarat. SEWA members have no fixed employer-employee relationship nor are they covered by protective labour legislation. SEWA’s membership can be categorized into four main occupation groups: (1) manual labourers and service providers, for example, agricultural labourers, construction workers and cleaners; (2) street vendors; (3) home-based workers like incense stick rollers and embroiderers; and (4) small-scale producers: gum collectors, craft workers and others. These women work long, hard hours, and because of the nature of their employment, they do not obtain even basic social protection such as health insurance, maternity benefits and sick leave.

Being the poorest of workers, and living most often in environments without basic amenities like water and sanitation, SEWA members and their families are often sick. The high cost of health care often prevents an informal sector worker from seeking treatment, which may result in the worsening of her state of health. Poor health, resulting in loss of wages and/or health care expenditures, leads to indebtedness, loss of assets and further poverty.

It was in this context that SEWA began to organise women for their economic rights three decades ago. Our goals are to organise workers for full employment and self-reliance – both in terms of viability of their economic activities and of decision-making and control. Full employment includes security of work and income, food security and social security. Social security, in SEWA’s experience, must include at least health care, childcare, insurance and shelter.

One of SEWA’s first initiatives, after its inception in 1972, was addressing women’s needs for financial services – savings and credit. This has been achieved through women’s own micro-finance organisation, SEWA Bank. Over the years, through SEWA Bank, we have learned that sickness is the major and recurring crisis in women’s lives. A study in 1977 of women who were not re-paying their loans regularly revealed that the major cause was sickness of the woman or her family members. We regularly witness women selling or mortgaging assets and utilizing their hard-earned savings during illness episodes.

SEWA’s Approach to Health Security

SEWA, over the years, has learnt that sickness is a major and recurring crisis in women’s lives. Constant calamities take a toll on women workers bodies, but they continue to neglect their own health while according priority to their families first. Despite facing constant health risks, SEWA members, especially in the rural areas, have little or no access to healthcare facilities. Whatever little healthcare they do obtain is generally curative care at high cost. Thus health-related expenditure today is found to constitute upto half the monthly income or Rs. 300-500 per month, in the case of women workers. It is also a major cause of their continued indebtedness.

SEWA believes that its members cannot have full employment without health security. From its early years, SEWA has been trying to devise ways to reach affordable, appropriate and sustainable health services to its members and their families. In 1984, a more structured community-based primary healthcare programme was started which is being implemented under the aegis of “Lok Swasthya Mandali” meaning People’s Health Co-operative.

SEWA’s Health Co-operative “Lok Swasthya Mandali” :

As part of our organizing work, SEWA has formed a Health Co-operative known as “Lok Swasthya Mandali” in 1990 with dais and health workers as its members and its focussed objective is “to bridge the gap between healthcare needs and healthcare availability, and help women and their families move towards health security and overall well-being”.

Lok Swasthya team is comprised of 400 local dais called ‘swasthya sathis’ trained in primary health care and midwifery, 60 community health workers (local leaders who have been provided with training by SEWA Health), and 100 full-time health organisers (or staff). This team works directly in Ahmedabad, Surat and Baroda cities and also in fourteen districts of Gujarat state through SEWA’s District Associations. Services are provided through 400 stationary health centres, 4 medicine shops, mobile health camps as well as home visits.

The activities of the Lok Swasthya Mandali include:

1. Provision of preventive health services, including:

		Health information and education, including information on HIV/AIDS;
		Immunization, iron and folic acid supplementation, and Vitamin A Supplementation, in collaboration with government services;
		Ante-natal care (ANC), including weighing, screening for anaemia, and nutrition Counselling;
		Skills up-gradation (of all SEWA Health functionaries) and training of midwives;
		Contraceptives – both by providing information and making these available by coordinating with government services;
		Screening for reproductive tract infections (RTIs) and cancer through diagnostic ‘camps’.

2. Promotion of health and well being. Health education is delivered through a six-module training programme for SEWA members, and slightly modified programmes for their husbands, adolescent girls and boys and traditional midwives.

3.  Provision of curative health services, including:

		Low cost medicines production and marketing ;
		Treatment of tuberculosis through DOTS method and screening and treating diagnosed persons;
		Mobile clinics called ‘camps’ for reproductive health problems, children’s and General health problems;
		Acupressure therapy;
		Ayurvedic (traditional medicine) treatment.

Approach to Health Security :
Lok Swasthya Madali’s approach towards health security encompasses the following:

1. Women led: The cornerstone of all of SEWA's health activities is to effect an improvement in the women's health status. The emphasis is on initiating a number of health activities based on local women's needs. While the "entry point" is women's health, the entire family's health is also safeguarded. In its twenty-year long experience of organizing poor women on health issues, SEWA has learnt that grouping the poor women into their organizations, including midwives and health workers’ organizations, is the most effective way of providing health security to the poorest members of the community.

2. Sustainability: SEWA has always believed in sustainability of its activities i.e. running these in an economically viable manner and by local women themselves. Thus local volunteers are developed as Sevikas and Aagewans. It is through these aagewans all the activities of SEWA Health are implemented. This results in a bottom – up approach of planning and implementing health activities.

As the poor organize and build their own organizations is that they become visible. And their bargaining power and voice increases, to the extent that they can demand that a non-functional primary health centre be re-opened, better services reach their doorsteps, mobile vans be pressed into service for remote villages in the desert and a full supply of essential drugs be available at the nearest health facility. Their organising can also result in traditional midwives, what we call “dais” in India, asking for an identity card from the government, as they have done in our state of Gujarat, so that referral to hospitals is facilitated.

3. Policy Action: The need to organize, unite and demand just policies for its members has always been an important par of SEWA’s activities. Thus, women are provided a platform to voice their concerns before the policy makers. For example, SEWA Health has been engaged in organizing dais in the form of co-operatives. They have collectively demanded and obtained recognition in the field of healthcare.

For example the dais were able to assert a demand for identity cards as a token for recognition of their services towards better health of their own communities through their co-operatives. A Government Resolution was passed in 2005 recognizing the state level Dai Sangathan which was formed to safeguard the interests of dais and recognizing them as health care providers.

4. Integrated and holistic approach: SEWA firmly believes that no programme can run in isolation if it is not intertwined with other aspects of the lives of women. In particular, all activities are developed keeping the primacy of work and work security in mind. In addition, activities have been interwoven to address needs of members like Insurance, Childcare and Housing which ultimately contributes to better health and well being.

For example the dais who are both members of the health co-operative as well as work as Swasthya Sathis in their own villages provide a range of health services like health education, primary health services, ensuring access to public health services like immunization and ANC, referral services, curative services like diagnostic and treatment camps, traditional medicines etc. Alongwith a holistic package of health services, she also works as an insurance promoter in her village by enroling women and their families in SEWA’s Insurance scheme known as “VimoSEWA” which includes an integrated package of life, health, asset and accident insurance.

5. Partnership with government and private health providers: Many activities of SEWA Health are run in partnership with government and private health providers with the dual purpose of strengthening the existing government health network and its optimum utilization and a greater access to quality services at a low cost from private providers. SEWA Health’s infrastructure and services have arisen largely to meet the healthcare needs voiced by SEWA members. But SEWA Health has also been shaped by its collaboration with many different partners. For example, the mobile reproductive and child health camps are funded largely by the United Nations Family Planning Agency (UNFPA). SEWA Health has been working in collaboration with the World Health Organization (WHO), the Government of India (GOI) and the Ahmedabad Municipal Corporation in providing DOTS (Directly Observed Treatment, Short Course) for tuberculosis to residents of the North Zone of Ahmedabad. The health education efforts are supported by the GOI, UNFPA and the Ford Foundation. These collaborations have benefited SEWA and its members, by providing financial and technical support to develop capacity for providing healthcare, and by facilitating access to government services and other resources that might otherwise have been inaccessible. In return, SEWA Health has been able to help these organizations in reaching some of the poorest informal sector workers

6. Services at Women’s Doorsteps: Services at SEWA Health are provided at the doorsteps of its members be it primary healthcare, diagnostic camps, health education or any other service. The purpose behind this approach is to make health services accessible to maximum number of women and their families and preserve their hard earned resources.

Provision of health services at their doorsteps according the needs of women and their families results in reaching the poorest as the services are provided at the timings suitable to them unlike the public health services which are more centralized and at timings not convenient to the poor. The health worker becomes a link between the community and the public health system which to an interface between the public health providers and further building trust on the system.

In fact health care seeking behaviour of the women improves if the service is available to them closer to their areas and at their convenient time. SEWA health workers and the health camp approach has clearly demonstrated this. Health services for the workers in the informal economy should be decentralized and community based. This also creates a demand from below for services that cannot be ignored.

7. Need based and Area Approach : The target population of SEWA Health’s activities is somewhat difficult to define. Initially, SEWA tried to provide services in neighbourhoods or villages where SEWA members were most concentrated. In these areas, SEWA Health provided healthcare to all women who sought it – members and non-members alike. All women making use of the services were encouraged to become full-fledged members of SEWA. This approach meant that only scattered pockets within the general population were covered. In recent years, SEWA has adopted a more geographical approach, providing services to larger blocks of the population, and enrolling almost all women in these areas as SEWA members. The “scattered” approach that was initially employed, made it was difficult to ascertain whether mortality and morbidity levels declined due to our health interventions – by comparing populations that had received SEWA Health benefits with those which had not. The geographical approach taken more recently, combined with an evolving management information system, has facilitated such comparisons in the future. In addition, approximately four years ago, men and boys – the male members of SEWA began insisting that SEWA also provide them with health information. These men had learned about SEWA Health’s activities from their women-folk, and now wanted to know first-hand about health issues including first aid and how to care for their children. It was also felt that in the matters of family planning and reproductive health a clear understanding of the issues by men is equally important. Hence, SEWA began organising men’s health education and developing a team of male health trainers and educators. The latter have even formed their own co-operative and are expanding their educational activities.