ASHA workers: The underpaid, overworked, and often forgotten foot soldiers of India

Lakshmi Vaghela (right) is the only Accredited Social Health Activist (ASHA) for the Waghjipur village of 1,000 people in Gujarat 

Image: Naandika Tripathi 

The sun beats down harshly on the deserted roads of Waghjipur village in Sanand, about 150 km from Ahmedabad in Gujarat. The occasional man walks around aimlessly at 9.30 am as we wait outside a blue, slightly dilapidated structure on a Wednesday morning. Minutes later, a lanky woman guides us inside the Waghjipur Anganwadi Kendra. “Hu Bharathi… Anganwadi worker, ASHAben aave che (I am Bharathi, the Anganwadi worker… the ASHA is on her way),” she says.  

Immediately after, Lakshmi Vaghela rushes in, taking giant strides and gasping for breath. “Sorry ben, badhe chalta javu pade che (Sorry, I have to walk everywhere),” she says apologetically. Vaghela is the only Accredited Social Health Activist (ASHA) for the village of 1,000 people.

Currently, all ASHA workers have been instructed to focus on vaccines. So Vaghela, mother of two sons, wakes up by 5 am and goes around the village underlining the importance of vaccination to its inhabitants. “Initially when the vaccination drive started, someone who had taken a dose passed away. Since then, people have been scared. During our first vaccination drive, only four people turned up,” she recalls. However, since the second wave of the coronavirus, people have become more accepting of the vaccine. “But right now, there is a severe shortage,” Vaghela adds.

The pandemic has drastically increased the workload of ASHA workers. They have to go for door-to-door surveys and contact tracing, convince people to get tested, distribute essential medicines and ration, and stick Covid-19 seals on households, apart from carrying out other responsibilities.

Despite the burden, Vaghela, 42, does not wish for help from another ASHA worker in the village. “With the workload getting divided, my already-meagre earnings would also get shared. If there are two pregnant women who I help with deliveries, I will have to share that with another ASHA worker… which means getting paid only for one,” she says.

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The second Covid-19 wave saw India doffing her hat to the medical fraternity—doctors and nurses who worked round-the-clock to save lives. However, the contribution of ASHA workers, who have been battling the virus in rural areas since last year, remain unacknowledged and forgotten.

Not only are they underpaid and overworked, but they have also been subjected to violence and abuse. Recently, an ASHA worker in Gorakhpur, Uttar Pradesh, was abused and assaulted while collecting details of local residents for Covid-19 vaccination. The frontline workers say verbal abuses are even more common.

“They’ve been facing this issue since last year. People are scared of them… they either shoo them away or shut the door on their face. But ASHAs continue to perform their duties. They don’t deserve to be treated like this. Strict action should be taken against those who use violence,” says BV Vijayalakshmi, general secretary of the National Federation of ASHA Workers. “They are the actual warriors in this fight [against Covid-19]. In fact, they’re not even given insurance. Nothing has been given to ASHA workers who passed away. Even if something happens to their family members, the government should provide help. The additional incentives announced last year haven’t been given till now.”

In June, more than 68,000 ASHA workers and community health activists in Maharashtra went on a week-long strike till the state agreed to fulfil their demands, which included a salary hike, among other things. Maharashtra Health Minister Rajesh Tope announced an increment of Rs 1,000 in their wages and Rs 500 as Covid-19 allowance per month from July onward. He also promised them a smartphone. Additionally, Tope declared Rs 50 lakh compensation for family members of ASHA workers who passed away due to Covid-19.

In Gujarat, the situation is equally bad. Though ASHA workers get incentives for every child they vaccinate or every delivery they undertake, they earn just Rs 3,000 to Rs 4,000 a month on an average. For Covid-19 work, the state promised them an additional Rs 1,000 per month. “It is almost a year-and-a-half, but we’ve not received the money promised to us,” says Soniya Hardikbhai Maheriya, 28, an ASHA worker from Changodar village in Sanand. She is one of six ASHAs who looks after the village of 13,000 people.

Suman Pujari, state president of Maharashtra ASHA workers’ union, says, “We have to protest and fight to get our demands fulfilled, otherwise no one takes ASHA workers seriously despite the fact that they’ve been a huge support system of the government in improving health care in rural India.” The government expected ASHAs to conduct Covid-19 RT-PCR tests too, but Pujari, 54, fought and ensured they did not have to do it as they were already burdened with work.

“ASHAs have been overloaded (with work) and in many parts of Maharashtra, they’re serving more people than their capacity. These ladies belong to poor families...but that doesn’t mean they can be exploited. In the last one year, more than 2,000 ASHA workers tested positive in the state, while 17 lost their lives. The family members of many also contracted the virus and some couldn’t survive,” says Pujari.

As of January, 44 ASHAs across India have died battling Covid-19, according to the central government. Though their job required them to come in direct contact with people, a majority of ASHAs were not provided with personal protective equipment (PPE), or masks, gloves and sanitisers. According to news reports, last September, a survey showed that only 75 percent ASHA workers were given masks while only 62 percent got gloves. ASHA workers interviewed by Forbes India say they have even less access to masks, gloves and sanitisers now than during the first Covid-19 wave. They either purchase it with their own money or use their dupatta to protect themselves from infections.

(L-R) Nisha Taviyad, Pushpa Parmar, Soniya Hardikbhai Maheriya, and Manisha Maheriya are four of the six ASHA workers that look after Changodar village in Sanand, which has a population of 13,000 people

Image: Naandika Tripathi 

Maheriya and her colleague Pushpa Parmar, 48, contracted the virus while conducting door-to-door surveys. While Parmar was quarantined at home, Maheriya had to be hospitalised, leaving her one-and-a-half-year-old daughter, also with Covid-19 symptoms, at home. “It was extremely difficult… after 14 days of quarantine, I had to immediately go back to work,” says Maheriya.

Both received government support, but some like Sangeeta Kamde, 34, weren’t as lucky. Kamde, who has been an ASHA worker in Maharashtra’s Sangli district for 13 years, is the sole earning member of her family comprising a disabled husband and two children. All of them tested Covid-19 positive recently. Kamde and her children were in home quarantine, but her husband needed urgent hospitalisation. There was no help from the government. After hopping from one hospital to another, she managed to find a bed in a government hospital. “We treat everyone without a second thought of catching the virus and transmitting it to our family members. But when I needed help, there was no one to support,” says Kamde, who starts her day early, finishes her household chores before going door-to-door for check-ups. In the absence of transportation, she has to walk 20 km every day. There are just four ASHAs in the district, handling 12 villages—which means one ASHA for 4,000 people.

Her monthly salary of Rs 3,500 is not enough for Kamde, so she seeks financial help from her mother and does part-time tailoring work during weekends to earn additional income. “Most of my salary goes in my husband’s medication. Every week I spend around Rs 300 to buy his medicines,” she says, hoping that her remuneration will increase in the near future.

While working on the frontline during the pandemic, ASHA workers have often had to protest  against the government for basics like a decent salary, masks, sanitisers, and gloves

Image: T. Narayan/Bloomberg via Getty Images

In 2005,the government launched the National Rural Health Mission and recruited ASHA workers to connect the vulnerable communities to health care. There are over a million ASHA workers in India. Ideally, one ASHA worker is supposed to cater to 1,500 people in her area. However, that is not always the case.

According to the National Health Mission, a woman resident of the village in the 25-45 age group can be an ASHA worker. ASHAs should have effective communication skills, leadership qualities and be able to reach out to the community. She should be a literate woman with formal education up to class eight. This may be relaxed only if no suitable person with such qualification is available.

Apart from carrying out regular tasks of antenatal and post-natal check-ups, immunisation, sanitisation, promoting hygiene and conducting surveys, ASHA workers have been working additional hours during Covid times. During the pandemic, services like administering polio and other vaccines have been put on the back burner.

“Poor transportation system, increased work burden and services not being provided in villages made things a lot tougher for ASHAs. In many cases, they are the sole breadwinners… falling sick meant that the household went for a toss and that cost is not being considered,” says Harish Hande, co-founder of SELCO Foundation that works closely with ASHA workers in Karnataka and Odisha.

ASHA workers earn incentives for 66 tasks, ranging from Re 1 for every oral rehydration solution (ORS) packet distributed to Rs 300 for each institutional birth and antenatal care, and so on. Many routine activities such as immunisation, check-ups of pregnant women and home-based newborn care were suspended during the lockdown. As a result, ASHA workers saw their incomes drop, sometimes by half, according to a 10-state study conducted by BehanBox between October and December 2020. Eighty-six percent of ASHA workers reported a drop in incomes from March 2020. In April 2020, the ministry of health and family welfare announced a Covid-19 incentive of Rs 1,000 for all ASHA workers, but 31 percent had not received it by the time the survey was conducted.

Despite the gloom, there is a silver lining. Some ASHA workers in Kerala’s Wayanad district have started receiving their salaries and incentives on time. Earlier, they would get salaries for two months together.

Vijithra is a 23-year-old ASHA who works with tribal communities in Karingari, Mananthavady  taluk of Wayanad in Kerala. She gets Rs 7,000 as stipend per month, including incentives

Image: Mexy Xavier 

Vijithra, 23, who is six-months pregnant, works as a hamlet ASHA worker in Karingari, Mananthavady taluk of Wayanad. She says the tribal community has been supportive of health care workers. Vijithra, who prefers to use only her first name, covers two colonies with 210 members each. She visits five houses a day, and spends at least half-an-hour with each family. “If they don’t see me once a week, they inquire and ask why I didn’t meet them. They’re like my own family now,” says Vijithra, who gets Rs 7,000 as stipend per month, including Covid-19 and other incentives.

Hamlet ASHA workers is a pilot project launched in Kerala in 2017 to prevent infant deaths in tribal areas. Educated, married women from the tribal community are employed as hamlet ASHA workers and allotted two to five colonies close to their homes. They undergo weekly training on Zoom calls and get suggestions from health experts on various topics.

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ASHAs are one of the most under-appreciated last-mile workers and it’s a model that can be replicated in any part of the world, says Hande. “ASHAs are knowledge-heavy people, but just because they don’t have a LinkedIn resume, we don’t give them enough importance.”

Issues faced by ASHA workers are at the structural, personal, health and community levels. They are fluid and inter-related, and should not be seen in standalone compartments, believes Dr Shaveta Menon, assistant professor at the Centre for Public Health and Health Care Administration, Eternal University. “Their standing in society restricts their professional role where they are not able to leave this job for better career opportunities as most of them are from low socioeconomic backgrounds. It is significant to note that in India, there is a refusal to recognise ASHA workers as workers providing labour. They are termed as ‘honorary workers’, and minimum wages and rewards associated with work are denied to them.”

ASHAs are a crucial link between community and frontline workers. “She [an ASHA worker] is part of a community, she understands the reality and challenges well. She can provide suggestions to frontline workers and also knows who is the most marginalised and the kind of issues that they are facing,” says Pallavi Patel, director of Chetna, an Ahmedabad-based NGO that works closely with ASHA workers. The NGO has developed a training module for ASHAs for the government of India. “ASHAs are being given a lot of technical information, but they need to develop certain skills like leadership, coordination and conflict resolution to successfully work well,” adds Patel.

Hande feels the profession can become attractive if the government increases the minimum salary. “The cost of the remoteness index can also be taken into consideration. For instance, you are paid more based on how remote you go. When the rich are getting paid more for going to remote areas to treat patients, why aren’t the poor?” he asks.

Most ASHA workers Forbes India spoke with want a salary hike and timely payment. They also demand insurance and respect. “The health system reforms for ASHAs should include financial protection, protection against sexual harassment, protection of physical and mental health, and stigma prevention with clear responsibility at all levels,” says Menon.

ASHA worker Maheriya says, “Family members tell us that we should quit, but we tell them that this is a service that we are providing.”

With inputs from Mexy Xavier