The indefatigable ASHA worker, central to India’s healthcare system, seeks proportionate compensation

The backbone of India’s rural healthcare system, Accredited Social Health Activists (ASHA) workers have played a major role in improving both maternal and child health, immunisation rates and the overall well-being of the community; they are also key to bridging the gap between rural communities and primary healthcare.

Ever since ASHAs were appointed in 2005 under the National Rural Health Mission (NRHM), they have played a pivotal role, including in spreading awareness about nutrition and sanitation facilities. During the COVID-19 pandemic, their role in healthcare expanded in an exponential manner.

ASHAs are selected from the community, primarily women between 25-45 years through a rigorous process involving community groups, anganwadis, self-help groups, village health committees, block nodal officers, district nodal officers and the general body of villages. After the selection, the ASHA workers go through a series of training programmes to enable them to execute their roles.

ASHA means ‘hope’ in Hindi, reflects what these workers bring to people from lower socio-economic backgrounds, through their roles. However, talking to ASHA workers reveals their side of the story – a not-so-happy story. Overworked and underpaid among frontline health workers, their anger and distress runs high. Ironically, this pink-clad all female group, won the WHO’s 2022 global leaders’ award, recognising their contributions to global health, leadership and commitment to regional health issues.

“Over the past 10 years, there were two or three prolonged strikes regarding the payment of salaries. The payment of ASHAs is based on the performance and the age of the worker. In addition, workers get certain incentives: initially this was a sum of ₹500. In 2015, the Central government increased salaries and they started getting ₹2,000, then in 2016 they got an increase of ₹1,500. Then in the COVID era, in 2021, they got an increase of ₹1,250. In 2024, there were strikes for a month, and they got a raise of ₹5,000 and certain additional performance-incentives. As of now, on an average an ASHA gets ₹16,000 per month,” says M.A. Patil, ASHA Workers Union leader based in Thane, Mumbai.

Despite these incremental pay raises, many workers continue to feel that their compensation does not acknowledge the true magnitude of their contribution to society. The work of ASHAs is not to be taken lightly. During the pandemic, they took Covid-19 tests, made sure home isolation was being taken seriously, and held awareness campaigns. The dark side of their work though is this — ASHA workers are said to be volunteers. Therefore, their core salary per month stands at a ₹3,000. This, of course, excludes the seemingly toxic point-based incentive system. Over the past few years, ASHA worker unions have staged protests all across the country, citing a lack of amenities and demanding the payment of arrears, as well as mental and social security services.

High maternal and infant mortality rates have often been a cause for concern in rural areas and have been pressing concerns, and ASHAs have been tasked with promoting hospital deliveries, providing antenatal and postnatal care and improving the overall health of children via immunisations and nutritional support. The NRHM has endeavored to construct a decentralised and community-based approach to health, and ASHA workers are key in facilitating healthcare. A study by Bajpai and Dholakia (2011) states, “The ASHA program represents an innovative attempt to involve local women in improving access to healthcare services, particularly in areas where formal healthcare infrastructure is weak.”

Forming sisterhoods

On the bright side, several women have found sisterhood in the circle. Neeraj Devi’s best friend Madhu, has been her only source of solace ever since her husband passed away in 2023. His death was a tragic accident. “Madhu has offered me warmth and told me to have faith in myself. She has been the one to assure me that this tough time of grief and poverty will pass.”

Madhu herself lives with her husband who has been physically abusive in the past. “I started working as an ASHA worker, hoping that I would, one day, be able to not depend on him. Being an ASHA worker enabled me to do that. The amount of respect that I have for myself is different, and I think it scares my husband that I do not depend on him. The money has enabled me to buy clothes and school supplies for my children.”

Madhu’s neighbour, Pinki Devi’s situation is somewhat similar. “My husband used to hit me with anything that he could find. I was married off at 17. My mother-in-law used to berate me and hit me as well. I’ve been suicidal. Being an ASHA worker has allowed me to step away from my family and gain some sense of self.”

For Neeraj, however, things look grim. “I used to love being an ASHA worker. I felt like I was truly making a difference to women’s lives. There have been cases when no one has been with the mothers apart from I. However the pay is so low, and the system of incentives, venomous. It takes a toll. After my husband’s death, I was torn apart. I slogged to earn about ₹9,000 [per month] with incentives. I have two young children who go to school. I can barely afford to pay for gas and food, and the burden of it all, breaks my heart.”

Working as employees, paid like volunteers

Madhu too agrees. “We have to work as though we are government employees but are paid as though we are solely volunteers. Often, deliveries happen at night. We leave our homes in the middle of the night, and our husbands often berate us, saying we are unable to give time to our families and the money is barely enough to justify that.”

Other issues also include harassment that the women face on the street, whilst spreading information about sexual wellness. “There have been occasions when men mime at us and make obscene gestures. All we can do is try to ignore them,” Pinki says.

Beyond the systematic challenges, ASHAs find strength in their community and amongst themselves. The journey of ASHA workers epitomises their dedication in the midst of extreme adversities. Their stories ask for the need for systematic reforms to ensure fair compensation, safe working environments and social security. As the backbone of India’s rural healthcare system, it is essential that their contributions are recognised and their challenges are addressed.

(The authors are freelancers. madhumitasharma9318@gmail.com and treya.sinha@gmail.com)