Image: Matilda Kullu.

Frontline health workers in rural India are fighting for better pay and permanent status

ASHA is India's million-strong community of frontline female health workers who connect rural India, especially its women and children, to health services and government schemes

Archana Tamdalge, 38, has lost track of the number of times she had to rush a woman in labour to the government hospital late at night or the early hours of dawn. In rural India, this can mean a journey of 6-8 kilometres or more, with no ambulance service. Often, she has spent money out of pocket on private transport for quicker transit. An ASHA worker, Tamdalge is responsible for the health of many women and children in Samdoli, a village in Sangli, Western India. Her compensation for ensuring a safe and quick delivery? Just Rs 300-Rs 600 ($3-$6) with no assurance of timely payment. “It’s not just me,” says Tamdalge, “but the story of almost every ASHA worker in India.”

ASHA, an acronym for Accredited Social Health Activist, means hope in Hindi. They are India's million-strong community of frontline female health workers who connect rural India, especially its women and children, to health services and government schemes. Chosen from village communities with mid-school level education, they are trained to monitor maternal and infant health for 1000-1500 people in the areas around them. They facilitate hospital deliveries, immunisations, nutrition supervision, disease screening, family planning and hygiene awareness among a total of 78 tasks and are paid incentives for these. 

ASHAs are considered volunteers and given a fixed incentive of Rs 2000 ($25) by the Indian government for their work across 34 states. Their additional compensation comes from the task-based earnings and remuneration they receive from the states where they live, varying from Rs 2000 to Rs 7000 ($85). These compensations come from different health ministry departments, making it fragmented and delayed, impacting their households.

Credited with lowering maternal mortality rates in India's rural areas, ASHAs were awarded by the World Health Organisation in 2022 but haven’t seen much change in their pay or working conditions. Frustrated and desperate, ASHA workers across India have been camping under the hot sun in Indian cities for the past few months, demanding permanent worker status, better pay, and benefits like a smartphone with Internet connectivity to enter data, a crucial part of their work.

Some Indian states like Odisha, West Bengal and Maharashtra have announced an increase in payments in March 2024. “Our compensation from the state has been increased to Rs 5000 more, making our whole pay scale higher. It took 14 years of agitations and protests on our part to achieve a large payout like this and this gives us hope for the future,” says Rohini Pawar, an ASHA from Walhe, a village in Maharashtra.

Maharashtra’s 75,000 ASHA workers went on a work strike in January 2024 and protested for over 21 days in Mumbai, part of it near the state chief minister’s residence. "It was tough to be away from home for so many days, sleep out in the open, spend extra money on food, accessing public toilets and transport. But we were determined that this time we will continue the fight as long as possible," Pawar says. Confident of the value they bring to rural healthcare and the necessity of their role, ASHAs have learned to raise their voice, supported by workers’ unions who help them amplify it.

But other states have yet to accept these demands and protests continue in many of them.

“It is no longer just about increasing our remuneration. It is about being made permanent workers,” says Laxmi Kaurav, an ASHA worker from the central Indian state of Madhya Pradesh. ASHA workers in Madhya Pradesh were promised Rs 4000 ($50) from the state. Kaurav says that they are yet to see this money come in regularly. Protesting against any atrocity can even land them behind bars or get them fired from their jobs. As the president of the ASHA/USHA Shramik Sangh, a scheme worker's rights group, Kaurav was taken into police custody in 2021 for raising her voice.

A Gendered Approach

ASHAs are seen as volunteers or activists and therein lies the problem, says Vahida Nizam, General Secretary, of All India ASHA Workers Federation. “ASHA workers were appointed in 2005 to improve the maternal and infant mortality rates. That is ongoing work, not just a temporary mission. It must be regularised and made a permanent department of the health ministry. Their demand for permanent status and payment regularisation is justified, as this is also the livelihood of the ASHA worker.”

A big reason is the regressive outlook towards women’s work. “Traditionally maternal and infant care work is viewed as women's work and not valued enough. The thought process among policymakers is men earn the main income and anything the women earn is secondary income, which is wrong,” asserts Nizam. “In the families of ASHA and other scheme workers, 50 per cent of the women are the breadwinners.”

ASHA workers worked almost 8-12 hours during the pandemic in India, including weekends. They were offered a raise of Rs 1000 which took months to reach them. Many say their rising workload is worrisome, impacting their physical and mental health. Currently, Kaurav's additional work involves screening people for sickle cell anaemia, a disease that the Indian government plans to eradicate by 2047. ASHA workers are also helping to create digital IDs for a government health scheme by visiting rural households and uploading their details online, often spending their own money for additional mobile data. Poor networks in rural areas make this job time-consuming. In February 2024, more than 70 ASHA workers were suspended in Madhya Pradesh for not completing this work. “We should have got prepaid mobile phones from the government to help with this. Many ASHA workers are not digitally trained or may live in areas with poor networks. Yet the government expected us to finish this work without offering any facilities or training,” a livid Kaurav adds.

Living in Hope

The All India ASHA Workers Federation has been exhorting the Indian government for regularisation of ASHA workers' services with a fixed monthly salary of Rs 18,000, based on the minimum wage calculation. Nizam feels this is the least the 10.4 million cohort of community health workers deserve after dedicating their time and energy to this work. It remains to be seen if this will be done.

The Indian government has now included ASHA workers under a free health scheme. There have also been initiatives across states to compensate them for higher education. However, their key demands of being made permanent workers and given benefits accordingly remain unmet. Even their hiked payouts remain way below the minimum wage requirement.

Despite this, ASHA workers remain hopeful and emotionally invested in the work. For many, the altruistic aspect takes over despite the snags.

Kaurav had dreams of becoming a doctor that she couldn't pursue. When the job of an ASHA worker came up, it allowed her to remain connected to the healthcare sector. "I can guide the underprivileged about free healthcare schemes offered by the government, which they may not be aware of, advise them on hygiene to help them stay disease-free," she says. Becoming an ASHA worker helped Kaurav step out of home, finance her education, and complete her post-graduation. She is now thinking of pursuing a Ph.D.

“I have spent so many nights in labour rooms holding a mother’s hand; so many days convincing villagers to seek medical aid and stop superstitious practices,” says Kullu, who was featured in Forbes India’s Power List for her Covid care work in 2021. “It took years of hard work to make this village my own. Money does matter but how could I have left all this effort behind just because of payment delays?” With her state Odisha not only increasing their pay to Rs 7000 ($85) and offering a service exit remuneration of Rs 1 lakh ($1200), Kullu feels their efforts have finally been noticed. Even if they had to fight for years.

Kaurav and other ASHA workers across other states in India are waiting for the same.