Health without wealth: the plight of India’s ASHA workers

One of the primary components of the National Rural Health Mission (NRHM) aimed at improving the health of the rural poor is to provide every village in the country with a community-based female health worker, known as an ASHA (Accredited Social Health Activist).

Selected from the individual village and accountable to it, ASHAs are trained to work as frontline healthcare providers, activists and educators at the community level. Their role involves connecting poor and marginalised rural communities to locally available public healthcare services and educating village residents about important health issues, such as disease prevention, good nutrition and correct sanitation practices.

Photograph iStock credit Sumit Saraswat

ASHAs therefore play a vital role in improving and supporting the health of poor villagers – from encouraging women to give birth in hospitals; to ensuring children are immunised against vaccine-preventable diseases; and providing drugs to treat (and therefore help prevent the spread of) life-threatening diseases like malaria and tuberculosis.

Crucially, they act as an advocate for improving female, neonatal and reproductive health and hygiene – such as providing contraception and family planning advice and ante- and post-natal care.

In May 2022, India’s one million-plus group of ASHAs, who are all females and classed as volunteers rather than employees, were honoured with a World Health Organization (WHO) Global Health Leaders Award for their “outstanding contribution” to protecting and promoting health. WHO director general Dr Tedros Adhanom Ghebreyesus saluted the ASHAs for their “crucial role in linking the community with the health system, to ensure those living in rural poverty can access primary health care services, as shown throughout the Covid-19 pandemic”.

The contribution of the nation’s ASHAs to the fight against Covid-19 hit the headlines after they made a vital contribution to limiting the spread of the disease, through activities such as contact tracing of infected people, coronavirus screening of migrants returning to villages and building villagers’ awareness of the disease and how to limit its spread.

However, commentators say they were often forced to work without suitable personal protective equipment (PPE), placing themselves and their families at risk of coronavirus infection, and were not assured of priority medical treatment if they became infected.

In fact, commentators say ASHAs and other government public health community outreach scheme workers have repeatedly been let down by the central and state governments in terms of poor occupational health and safety standards and working conditions.

Incentive payments
ASHAs are considered to be volunteers, rather than employees, and instead of wages are generally paid on an incentive-basis. For example, ASHAs are paid for ensuring a woman gives birth in hospital or ensuring a child receives a full programme of immunization against vaccine-preventable diseases.

States are also allowed to pay a small, fixed monthly basic salary to ASHAs. However, campaigners say that the typical monthly income of an ASHA is far less than the minimum wage. There have also been allegations that some states have given ASHA new tasks without clearly setting out the level of payments that will be made for completing the duties, and have even failed to pay for the completed new tasks.

As a result, for years, ASHAs – led by their trade unions – have been demanding that their employment status should be formalised and regulated to ensure they receive minimum wages and social security coverage and benefits, such as pensions.

But unfortunately the central government has not paid any heed. Activists say that many ASHAs are not even paid, which shows that even today in India, women workers are considered second-class workers. “It is a matter of regret that these women workers who work day and night do not even come under the ambit of the labour laws of our country and that is because the government does not consider them as workers,” said an activist.

In December 2022, thousands of ASHA workers from Haryana marched to the state’s Vidhan Sabha (legislative assembly) in Chandigarh to present their age-old employment demands to the state’s politicians.

The protesting ASHAs said they should be made permanent employees, and be provided with all appropriate social security benefits, including retirement benefits. They also called for a minimum wage of Rs 26,000.

The call for the assembly march was given by the ASHA Workers Union, Haryana, which is affiliated with the Centre of Indian Trade Unions (CITU).

Addressing the protestors, ASHA Workers Union Haryana state president Surekha said that ASHAs have been serving the Haryana health department for the last 17 years, working as an important link between the health department and the general public to implement all of Haryana’s health department’s schemes at ground level.

According to the NewsClick website, ASHA union state president Surekha said that for 17 years, the Haryana government had refused to pay salaries to the state’s ASHA workers and had refused to make the ASHAs permanent employees.

“We strongly condemn the anti-workers attitude of the [Haryana] government and demand that all workers should be made permanent employees. Rs 26,000 minimum salary should be given. All social security benefits including retirement benefits should be given,” she told NewsClick.

Battle for improved rights for government scheme workers
In November 2022, around 4,000 workers from various government-funded and government-run public health outreach support schemes from states like Chhattisgarh, Andhra Pradesh, Maharashtra, Jharkhand, Bihar, Uttar Pradesh, Uttarakhand, Assam, Punjab, Delhi and more gathered at Jantar Mantar in New Delhi under the banner of ‘Rights and Respect Mahadharna’.

The protest was organised by the All India Scheme Workers’ Federation (affiliated to the All-India Central Council of Trade Unions, or AICCTU), which is running a nationwide campaign calling for improved rights and dignity for government scheme workers.

These scheme workers include ASHAs, Anganvadi workers (who provide basic health, childcare and food services in impoverished villages), and Mid-Day Meal (MDM) workers, who provide free lunches on working days for children in government primary and upper primary schools.

Shweta Raj, general secretary of Dilli ASHA Kamgar Union (part of the AICCTU), said: “On the one hand, the ASHAs have been honoured with the ‘Global Health Leaders Award’ by WHO. On the other, they do not get a respectable salary, do not have fixed working hours and are regularly mistreated in dispensaries and hospitals.

“Many ASHA workers lost their lives while on duty during the pandemic but their families have not received any compensation so far.”

NRHM guidelines state that an ASHA should be an ‘honorary volunteer’, not receive any salary and her work should not interfere with her ‘normal livelihood’. An ASHA’s workload is supposed to consist of just two to three hours, four days a week, along with some extra events. This is based on the premise that the work of an ASHA is meant to be just a supplement to the worker’s main livelihood. 

Photograph iStock credit Sumit Saraswat

Casual nature of the work
However, the main issue is the informal and casual nature of the work, status and employment rights of ASHAs. “The contractual nature of the job deprives the women of their rights and social security benefits, leaving them with no ability to demand better wages or working conditions,” say experts.

“They often suffer from delayed payments, long and unregulated work hours, lack of decent working conditions, and absence of grievance redress mechanisms.”

Commentators add that despite the intended part-time nature of the role, most ASHAs work between 25-28 hours a week, and sometimes more.

During the pandemic, alongside carrying out their usual public healthcare duties, ASHA workers were placed on the frontline of the government’s pandemic response. They were tasked with going door-to-door in containment zones to screen people for possible Covid-19 infection, and had to arrange for formal testing of those suspected to be infected. ASHAs also had to take infected people to quarantine centres, or assist them with home quarantine. The ASHAs were working long hours, seven days a week, without access to proper protective equipment. 

In August 2020, there was a nationwide strike of 600,000 ASHAs, and over the past few years there have been strikes and protests in various states, including Karnataka, Madhya Pradesh, Haryana, Punjab, Gujarat, West Bengal and Kerala.

“The extra burden of pandemic-related duties, lack of protective gear, harassment by the public and delayed payment of Covid honorariums have led to this breaking point, for workers who were already underpaid and overburdened,” said Shruti Ambast of the Centre for Budget and Governance Accountability (CBGA). 

“In 2020, it was found that because of additional pandemic duties, ASHA workers across India had been working an average of eight to 14 hours a day in the field, including on weekends,” noted Ambast.

In light of the publicity around the health risks faced by ASHAs during the pandemic, the National Human Rights Commission (NHRC) highlighted their “poor working conditions”. It also asked the central and state governments to provide details about the number of ASHA workers active in each state, their status, the amount of remuneration they receive, other dues paid to them during the pandemic, any arrears in payment and the various health protection measures in place to safeguard workers from contracting Covid-19.

Campaigners say the working conditions of ASHAs deteriorated when the pandemic hit and have continued to deteriorate. During the height of the pandemic, scheme workers, especially ASHAs, besides fulfilling their usual public health duties, took on the arduous task of combating the virus and becoming a vital communication link between people, doctors and hospitals.

They played a crucial role in gathering vital data about the spread and extent of the coronavirus in the community that helped the government frame policies to tackle the emergency. Most of their work, which put their lives in danger through potential infection, was done without any major incentive.

“ASHAs must be reclassified as employees, provided regular pay over and above the minimum wage, and commensurate with their nature of work, and be brought under long-term social protection,” adds Shruti Ambast of the CBGA. “They must also be provided opportunities for specialising in specific areas of health, and for moving up to higher positions in the public health system.”

The existing policy framework for ASHAs, based on regressive classifications of women’s labour, does not support adequate compensation, and is in need of a complete overhaul, she added.