ACCREDITED SOCIAL Health Activist (ASHA) Workers may have been honoured by the World Health Organisation for their crucial contribution in linking community with the health system, but they remain a workforce deeply underpaid. India Ahead when spoke to Asha workers based in Delhi, they said that because of the low income they have to take up a second job – usually as domestic help to run their homes.
India’s one million all-women ASHA volunteers were honoured by the World Health Organisation on Sunday for their “crucial role” in providing direct access to healthcare facilities in rural areas. The WHO said in their statement said that the women were being “honoured for their crucial role in linking the community with the health system and ensuring that those living in rural poverty can access primary health care services”. The organisation also pointed to their contribution throughout the Covid-19 pandemic, which helped to ensure those living in rural poverty could access primary health care services.
One of those who did all this includes Neelam. She joined the ASHA workers team in 2016, three years after her husband passed away. She had to support her children, and despite having studied till 12th grade, she couldn’t find any other employment but being a domestic help and becoming an ASHA worker. With making just around Rs 5,000 to 6,000 every month, she also took up the job of a domestic help and continued to raise her two children.
So, every morning she first heads for her work as a domestic help, cleans dishes, sweeps and mops floors, comes back home to make breakfast for her children, and then heads off for her daily rounds in the clinics and the homes she oversees in her area of Begumpur Park of Malviya Nagar.
Every ASHA worker has about 2,000 people whose healthcare they have to oversee.
The central governments website on National Health Mission says that ASHAs receive performance-based incentives for promoting universal immunisation, referral and services for Reproductive and Child Health (RCH) and other healthcare programmes, and construction of household toilets.
Neelam in conversation to India Ahead said that there are 12 points to look into, out of which at least six should be achieved to receive a decent incentive. These include adding new pregnant women to oversee, to get senior citizens cataract operation done, oversee and speak with male and female members for vasectomy or sterilisation, respectively.
While this remains their monthly tasks, their added work came in with the Covid-19 pandemic in 2020. Rajib Dasgupta, chairperson of the Centre of Social Medicine and Community Health at Delhi’s Jawaharlal Nehru University, told India Ahead that across the states, ASHA workers played a key role in Covid-related activities at the household and community levels, particularly in the rural contexts.
“As surveillance was a key activity in containing this new highly infectious disease, state/district health services relied on ASHAs to be the face of the health department. Their outreach was a critical step in reaching out to individual and family levels; some countries relied on technologies such as apps to do this; but India was able to do this with a human touch to it.”
Neelam, described Covid-19 as one of the hardest times she faced, with not just the threat of contracting the virus, but where their hard work remains unrewarded. The heat was scalding, and people were discriminatory. “It felt like being untouchables where if we would want water, the public would not want to give it to us, if they did, they wouldn’t refill the bottles because they didn’t want to touch it.”
The ASHA workers during the height of Covid-19 were first put on the job to oversee the quarantine of persons arriving from abroad. They also later became an important part of going into containment zones, facilitating patients’ recovery and checking on others to see if they had contracted the virus. Their work continues to see people getting vaccinated and boosted with Covid-19 vaccines.
Yet, for their work during Covid-19, they were not paid any extra amount. While later the central government promised Rs 500 for Covid duty per day of work. But even before this, the promise in 2018 by the central government to increase their monthly remuneration by Rs 1,500 has not happened yet.
Rekha Balhara remembered the day her Covid-19 work began, in her area of Neb Sarai in Saket. It was March 16. The 45-year-old Balhara who has been working as an ASHA worker since 2011, said, “We have done unlimited work. From our routine work of looking after pregnant women to the immunisation of children and care for the elderly, we did and continue to work to combat Covid-19.”
Their protest in 2021 for two months demanding a minimum monthly income of at least Rs 15,000, was thought to have moved the Delhi government to take their demands into account. Yet, months on and still no results, means Rekha and many others she knows have discussed leaving the service. “Yes, we want to do this work and help people but it’s not something we can do for free. We also need proper wages. All the Delhi government has done is make electricity and water-free, who does it benefit? People living in rented flats still have to give a monthly payment to their landlords. This isn’t a scheme which has worked for us.”
“This award means nothing to us as it wont change a thing… Modi ji (Prime Minister Narendra Modi) may wish us for this award, but the fact still does not change that nothing has happened for us.”
But the tragedy is, she said that for the government even if she leaves and others too decide to, there will be others more than willing to take her place, despite being acutely underpaid. “There is so much unemployment that even a graduate will take this job.”
Professor Dasgupta pointed to the importance of the ASHA cadre since its inception in 2005, which has significantly transformed itself and in turn the health services in the country. “That it has become the sheet anchor of primary healthcare in India is no exaggeration. If anything, there is an over-reliance on this layer,” he added.
As for the questions on the future and the workers, he says that the key challenge remains the lack of clarity as to what role the ASHA workers play. “Are they volunteers, community health workers or as the acronym suggests activists? This is neither a novel nor a new question. This has a bearing on training, responsibilities, skills and remunerations.”
He added that what would be central to the next-generation health sector reforms is to recognise the ASHA workers as community health workers and appropriately skill them. This would mean recognising them as a formal cadre, and not a loose voluntary arrangement, and empowering them with requisite salaries and career progression avenues.
As India urbanises fast, the nature of activities in primary health care services are going to transform itself, and ASHAs have a key role to play.