#Aftermath || For those who give ASHA, there is little in return


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For those who give ASHA, there is little in return

By Nandhini Shanmugham

Nandhini Shanmugham is a development communications consultant.



As the COVID-19 count in India continues to rise, efforts are being made to capitalize on all existing resources in the health-care system to contain the spread of coronavirus. These efforts include leveraging the services of around a million ASHAs (Accredited Social Health Activists).

With doctors and nurses tending to patients in hospitals, which are beginning to feel overwhelmed, it is health-care workers, like ASHAs, who now find themselves at the frontline battling the pandemic.

ASHAs entered India’s health-care system as a volunteer cadre in 2005 under the National Health Mission to essentially act as an interface between communities and the public health-care system. Recruited from marginalised communities, ASHAs have played a decisive, but often unrecognised, role in improving child and maternal health indicators and bridging the gap in healthcare delivery to marginalised communities.

From promoting good health practices and mobilising community towards local health planning, ASHAs now have additional responsibilities – house-to-house surveys, collecting travel history, contact tracing, creating awareness, ensuring that home quarantine is being followed and undertaking other healthcare and relief measures assigned to them. And they are doing so under very challenging circumstances.

In the initial days of the pandemic, many ASHAs were undertaking their COVID-19 responsibilities with little or no protection. In an in-depth interview done with 52 ASHAs across 16 states, the survey by BehanBox found that “workers were being overburdened with work, lack of protective gear and poor economic compensation.” It was only after repeated stories by the press, did the Government issue a directive in April asking States to provide all ASHAs with PPE kits. Some have received it, some haven’t.

Despite being volunteers from the community, ASHAs have, unfortunately, also borne the brunt of stigmatisation during the pandemic. Ill-informed residents lashed out on health-care workers and abuses and taunts were being hurled at them repeatedly.

In a webinar conducted by Women in Global Health, Surekha, general secretary of the Haryana ASHA workers union, said, “Attacks on ASHAs from Dalit communities in Haryana are high especially from the landed community strongmen as a means to assert their caste supremacy once again.”

Even within their homes, ASHA workers have had to deal with the guilt of going against their families’ wishes and continuing to serve. Worried about the risk of exposure, families are concerned for the safety and well-being of ASHAs. Is it really worth the risk? Given the increasing unemployment and volatility of the job market, healthcare workers are left with little choice but to stick on to a thankless job with poor wages.

Despite the monthly entitlement by the Central Government (Rs. 3,500-Rs. 4,500), on completing certain core activities, ASHAs in most states don’t receive a fixed honorarium. The only exceptions being the states of Karnataka, Kerala, West Bengal, Haryana, Andhra Pradesh and Sikkim which pay a fixed honorarium every month. In addition to the honorarium, ASHAs are eligible for incentive-based fee for facilitating certain healthcare services. The range of incentive among the list of activities can be as little as Re. 1(per pack of 6 sanitary napkins distributed to adolescent girls) to Rs. 300 (for institutional and antenatal care). And the payment is, almost always, delayed by months.

According to the report ‘Working Condition Of ASHAs’ (2009-10), ASHAs, who were meant to work for 2-3 hours a day, have been clocking in more than eight hours a day in the past few years. And while this has only increased during COVID-19, the same cannot be said about their payment.  Their risky and tireless efforts are being acknowledged through a measly incentive of INR 1,000 (to be paid from January – June). “Who wants to go out? But the virus of hunger is bigger than Coronavirus. My life’s value is 30 Rs per day but I have no option, my only urge is to get a little more money,” expressed Nirmala Mane, an ASHA worker from Satara in her interaction with writer Snehal Mutha.

The story is no different for another group of frontline workers – sanitation workers – whose efforts are unmistakeably crucial, but whose repeated pleas for better work conditions fail to garner attention and action. Guidelines issued by the Ministry of Health and Family welfare state that sanitation workers are to use N-95 face masks, gloves, coats, boots, and sanitisers in their job. Yet many continue to perform their jobs without any PPE.

Around 50% of urban sanitation workers are women. They collect municipal solid waste collection, sweep roads and clean school toilets. In a recent article on sanitation workers, Amnesty International India highlighted challenges women sanitation workers faced prior to the pandemic. This included disparity in wages, inadequate protective gear, poor access to toilets and non-payment of wages during maternity leave. In the current context, while existing challenges remain, women sanitation workers now have to put in extra work in new areas. In the absence of public transportation, this has meant long hours of walks; there have been instances of sexual harassment reported by some women sanitation workers near Madurai; and with schools shut, many are forced to leave their children unattended at home.

Sharing her thoughts on the gender disparity in wages, Uma, from the Institute of Development Education, Action and Studies, Madurai, said, “While all panchayats do not pay for the additional disinfectant work, the panchayats that pay do so differently for women, who are paid Rs. 250/- per day, as compared to men who are paid Rs. 500/- per day.”

The fight against COVID-19 is going to be a long and tough one. In the months to come, as we begin to ‘unlock’ more, and as measures to contain the virus gain momentum, the role of ASHAs and sanitation workers will become even more significant. But what will be more important is whether or not we change the way see and treat them.

A Government evaluation of the ASHA programme showed that most ASHAs had a monthly family income of between Rs. 1000 and Rs. 3000. 22% of ASHAs in Odissa, 18% in Assam and about 10% in Bihar and Rajasthan were the main breadwinners for their families. Given this economic context, it is no surprise that ASHAs have been calling for social security, a fixed monthly pay of Rs. 18,000 and other benefits. Action on the part of Governments has been slow. In Haryana, it took seven months of protests for ASHAs to be paid a salary of Rs. 4,000. Further south in Andhra Pradesh, it was a 10-year-long struggle that got ASHAs a monthly salary of Rs. 10,000.

If governments want this pool of corona warriors to continue serving communities, then the least it must do is ensure fair remuneration. How many more years of protesting and how many more pandemics is it going to take for their voices to be heard?

Nandhini, Front-line workers pic

Community health workers, like this group in the Upper Tons Valley in Uttarakhand, are battling the pandemic at the frontline without adequate protective gear. Photo courtesy: Kalap Trust

Health-care professionals and NGO representatives, who the author spoke to on condition of anonymity, expressed apprehension on any dramatic changes for ASHAs. Some said it won’t be a complete surprise if disgruntled ASHAs give up this work and look for better paid work. Or there is also the possibility that some states like Tamil Nadu, which had restricted the recruitment of ASHAs only in tribal areas, may consider recruiting more ASHAs to strengthen healthcare service and delivery.

“We are like worms in the eyes of our higher officials because we come from poor families and have studied only upto 10th grade,” said Pochamma from Andhra Pradesh. “Sometimes, ASHAs struggle to maintain records. They shout at us and call us incompetent. Just because we struggle with writing sometimes, does it make our work any less important?”

ASHA workers surveyed by BehenBox expressed their disappointment both with their work conditions and the manner in which they have been treated by the government. Many said they have considered quitting their work for a better paid job. It was also found that ASHAs have not been included in Ayushman Bharat, the national public health insurance scheme, nor state health insurance schemes, except in some states, despite the Government’s claims in a Lok Sabha reply that they were entitled to such social security benefits.

What is clear from all that is written about community health workers is that the disparity in treatment is systemic. Instead of symbolic policies, there needs to be committed action that will help ASHAs and sanitation workers. This can include special benefits, like maternity care, education scholarships for children and access to finance for improved livelihoods. Some state governments have assured doubling the basic pay for healthcare staff such as doctors, nurses, laboratory technicians and ambulance drivers. ASHA workers did not find a mention in the list. Why?

Rather than seeing them as volunteers, ASHA workers feel that only when they become an integral part of the health-care system with proper rights and benefits will their exploitation stop. Could COVID-19 be the catalyst for this much needed change?

The pandemic does provide an opportunity to strengthen the support structures which, by the Government’s own evaluation, are weak in most States and were “set up as an afterthought rather than as a priority activity.” According to the ASHA guidelines, the role of NGOs lies in both institutional arrangements and in training. However, in most States, the role of the NGOs has been restricted to training functions. Much of the weaknesses of the ASHA programme can be traced to this weak support structure. The pandemic has already made it clear that India must make more investments in public health. And when that happens, strengthening support structures must definitely be given due consideration.

Change management workshops, across the board, may help in bringing out an attitudinal shift in the way community health-care workers are perceived. Sustained motivation through well-thought incentives will keep the morale of this workforce high.

If we are ready to acknowledge the visible improved health & hygiene indicators which ASHAs and sanitation workers have helped achieve, then why do we fail, as a society, in acknowledging their rights? While we see doctors stand up for their peers, and nurses do the same, who stands up for ASHAs? When support from within the fraternity is skewed, what hope can ASHAs have from the rest? Who will stand up for the sanitation workers who diligently, and at great risks, are keeping our environment sanitised?

Every crisis is an opportunity. And so is COVID-19. Can State Governments and Health officials use the pandemic as an opportunity to listen, reflect and respond to the pressing challenges our community health workers face? And can they do so with empathy and courtesy.

While evaluating the ASHA Programme, workers were asked to cite the top three reasons for becoming an ASHA. 80% of all ASHAs across the districts reported “serving the community” as the top reason. In a post-pandemic world, it’s left to see how we serve this remarkable and understated group of corona warriors.

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