Overworked, underpaid: Why govt is deaf to ASHA workers’ demands

A fleet of women volunteers–Accredited Social Health Activists (ASHAs)–has revolutionised the last-mile health care system across the complex Indian landscape. In one of their many achievements they have ensured more and more women in rural India give birth in hospitals. Part of the National Health Mission (NHM), close to 9,00,000 such activists, more commonly identified as ASHA workers, criss-crossing the length and breadth of India have made a positive impact by ensuring that people listen to them while making critical decisions on family planning and immunisation services. Their voice for their own rights, however, has largely remained unheard.

On March 15, ASHA workers from Delhi, Haryana and Punjab held a protest march at Jantar Mantar demanding an increase in budget allocation, minimum wages and pension. Their protest, however, is neither new, nor limited just to the national capital.

Thousands of ASHAs have been staging protests across states, demanding that the government fulfil their long-pending demands. The protests have been incessant since the past four months in states, including Haryana, Punjab and Telangana.

The demonstrations began after repeated demands, made over several years, went ignored even as their workload mounted and working conditions worsened.

Shila Devi, an ASHA from Rohtak district of Haryana, told The Federal, “We are asking the government to meet our demands from the past three years. No one listened to us. Now we had no option but to protest. We have been protesting for the last four months, but still, no one pays heed. The current honorarium is meagre, lower than the salary of contractual unskilled workers. We just earn Rs 4,000 per month.”

Shila Devi’s last salary hike was in June 2018 when she and her colleagues got a Rs 350 hike from Rs 3,650 to Rs 4,000. “The strike has been launched to demand implementation of an announcement made by Prime Minister Narendra Modi in September 2018, to increase our monthly honorarium by Rs 1,500,” she explained.

Kulwinder Kaur, an ASHA from Ludhiana in Punjab, said, “Forget about an increase in salary, we are not even getting the income which was promised to us since the last eight months despite working day and night.” In Punjab, ASHAs are protesting for not being paid the prescribed remuneration to the workers who worked during the Covid vaccination drive for eight months.

The plight of ASHA workers in Delhi is no different from those working away from the capital city. Rajni Varma, a Delhi-based ASHA worker, said, “Our funds get delayed. We are paid very little. Despite the government’s promises, again and again, we are still living in bad conditions. We have to sell ornaments or some house items sometimes to make ends meet. Since the price of everything is skyrocketing, it is getting difficult for us to feed our children.”

Perpetual fight

Instituted under the National Rural Health Mission, 2005, ASHA workers are meant to be an “interface between the community and the public health system”. As per the NHM’s website, they are often the first point of contact for any health-related demands of “deprived sections of the population, especially women and children, who find it difficult to access health services”.

But from the very beginning, ASHAs have been living in a perpetual state of deprivation. Over the past 15 years, ASHAs have staged various protests to make voices heard, but without any positive response from the government. In 2007, the Bihar Police caned and then fired water cannons to disperse hundreds of ASHAs who staged a protest in support of their demands.

In 2009, ASHAs lodged a protest in Punjab. Demanding fixed monthly remunerations and confirmation as permanent employees, members of Karnataka State ASHA staged a protest near Freedom Park in 2011. In 2013, thousands of ASHA workers from all over Haryana organised a rally in Rohtak and marched towards the chief minister’s residence. They were protesting against the injustice and unfair treatment meted out to them.

In 2015, scores of ASHAs in Delhi launched an indefinite strike, staging a protest outside Chief Minister Arvind Kejriwal’s residence demanding regularisation of services and fixing of minimum wages. In 2016, the government introduced Asha Soft, a web portal linked to the mother-child tracking system to make it easier to pay ASHAs. However, it is making life harder for the foot soldiers due to issues such as power cuts, the lack of computer knowledge and internet access.

After 2016, every year ASHAs staged a nationwide protest with their demands. The demands mostly include a fixed and better salary, humane working conditions and fixation of their post with the government ending their contractual employment. With the onset of Covid in 2019, the ASHAs struggled to get masks or any other safety equipment while going door to door for checking people’s health. They again had to stage protests for appropriate safety equipment. While other frontline workers were appreciated, the salaries of ASHAs were stopped for months citing losses.

The fact that for the last few years some or the other state has been witnessing an ASHA workers’ protest speaks volumes about their job satisfaction. Sunita Devi, general secretary of the ASHA Workers’ Union (AWU) in Haryana, said, “I took part in nearly 40 protests across the country. The fact that ASHAs have to protest always to get the government to listen to them is really depressing. The government doesn’t treat ASHAs fairly and that is why we have to protest.”

Role of gender

ASHAs–a cadre of over one million female community health workers–often experience low status and precarious working conditions. Even though ASHAs are considered a game-changer for the NHM, they are still not recognised as full-time formal employees and receive inadequate, irregular honorarium payments combined with monetary and material incentives.

On an average, ASHAs earn between Rs 4,000 and Rs 5,000 per month for what is effectively full-time work. Incentives offered are also insufficient. For example, accompanying women to give birth at hospitals is incentivised, but travel for critical antenatal check-ups is not.

The wage gap persists even for female doctors, who are highly underrepresented. While there is little data from India and other low-middle-income countries, numerous studies conclude that female doctors earn 20-29 per cent less than their male colleagues, globally. This may reflect the predominance of men in higher-paying leadership positions.

One review indicates that only 25 per cent of global health organisations have gender parity at senior management levels, and 20 per cent of organisations have gender parity in their governing bodies. Manju Panchal, an ASHA based out of Delhi, said, “We are not getting fair treatment from the government because we are women. If we were men, the salary structure may have been different and good. The government considers us as part-time workers and secondary citizens.”

Deepa Narayan, a women activist, said, “ASHAs are facing the same problem as every other woman in India. We are not entitled to get anything without fighting for it. We have to raise our voices. The government also took this lightly, perhaps thinking that whenever the workers protest, it will increase their salary, otherwise not.”

Surekha Dalal, an ASHA leader from the Centre of Indian Trade Unions, said, “Earlier, the government used to accept the demands of ASHAs whenever we protested. That was a major boost, at least we can ask for our rights. After 2016, every ASHA knew their rights and how to get them. ASHAs are not full-time government workers. So the government never increased wages and benefits for them. That is why ASHAs started taking the route.”

She strongly feels gender also plays a role in all this. “ASHAs are mostly women from poorer socioeconomic backgrounds. The government very smartly took the decision to hire such vulnerable women so that it has to shell out less on their salaries. Now, the government is citing Covid and the lack of funds as excuses, but only for ASHAs. Salaries of ministers, central and state employees are increasing every year,” she added.

Policy lapse

The existing policy framework for ASHAs, based on regressive classifications of women’s labour, does not support adequate compensation. The NRHM guidelines state that an ASHA would be an ‘honorary volunteer’, not receive any salary and her work would not interfere with her ‘normal livelihood’. The ASHA’s workload was supposed to be just two-three hours, four days a week, along with some extra events.

This categorisation is based on the premise that the work of an ASHA is just a supplement to the worker’s main livelihood. However, it was seen that most ASHAs were working between 25-28 hours a week, and even beyond that. In 2020, it was found that because of additional pandemic duties, ASHA workers across India have been working an average of 8-14 hours a day in the field, including on weekends.

This characterisation of ASHAs as community volunteers or activists reflects the continued devaluation of women’s work, which is a widespread trend in low-income countries. It also signals the government’s unwillingness to invest in a regular cadre of human resources for public health in rural areas as it would have long-term fiscal implications.

Given the categorisation of ‘volunteer’, neither the Union Government nor states have any legal obligation to pay ASHAs a minimum wage. ASHAs earn money through task-based incentives under the NHM, which is funded in a ratio of 60:40 between the Centre and the states.

There are over 60 tasks under the NHM for which states can set incentives for ASHAs. These range from Re 1 for distributing items such as ORS packets, condoms or sanitary napkins to households, to Rs 5,000 for facilitating treatment and support to a drug-resistant TB patient. In 2018, the Union government doubled the incentives for a certain set of routine and recurring ASHA activities from Rs 1,000 to Rs 2,000. An amount over and above the NHM resource envelope was offered to states for this purpose, although they were free not to use it.

Some states pay ASHAs a fixed monthly amount in addition to performance-based incentives. The scope and amount of incentives vary among states, therefore, ASHA workers’ monthly earnings can differ widely. In spite of states supplementing the income of ASHA workers from their own budgets, the supplements do not amount to much when matched with the nature of tasks and the workload of ASHAs. For instance, Rajasthan and West Bengal pay a fixed minimum of around Rs 3,000. However, even when combined with performance-based incentives, an ASHA’s average monthly earnings do not match the minimum wage for a highly skilled worker.

Shruti Ambast, senior policy analyst at the Centre for Budget and Governance Accountability, in her research on ASHA workers said, “The poor status of female frontline workers in India reflects a regressive outlook towards women’s employment, particularly that of the most disadvantaged women. Workers like ASHAs do not have adequate opportunities for upskilling and improvement in pay, and they remain stuck in the informal economy, while continually being burdened with new areas of work. At the same time, the rate of women’s workforce participation in India remains low and has even declined in some areas, reflecting a lack of remunerative jobs.”

“ASHAs must be reclassified as employees, provided regular pay over and above the minimum wage, commensurate with their nature of work, and be brought under long-term social protection. 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,” she added.

In its defence, Haryana’s health minister Anil Vij, told The Federal, “We are holding meetings with ASHAs. The salary for ASHAs in Haryana is already higher than all other states. But we are still talking to them to reach a consensus.”

However, Union Women and Child Development Minister Smriti Irani earlier said that an increase in the remuneration must be done by the state governments even though the central government has finalised some social security schemes for the workers.

Amid all such claims of ensuring women-led development by the government, ASHA workers continue their protest with a hope that someday they would be heard. But for now, their struggle continues.