ASHA Crisis

INTRODUCTION

Accredited Social Health Activists (ASHAs) form the backbone of India’s community healthcare system, bridging the gap between rural populations and formal medical services. Despite their critical role, they face systemic neglect, including lack of formal recognition, inadequate pay, and absence of social security.

Key Facts About India’s ASHA Programme

• Origins in Chhattisgarh (2002): 

• The Mitanin programme was launched in Chhattisgarh to provide community-based healthcare, particularly for resource-deficient and marginalised communities.

•  In the Chhattisgarhi dialect, ‘Mitanin’ translates to ‘friend,’ signifying the compassionate and trust-based role they played in their communities.

• Launch and Objective:  The success of the Mitanin model led to the creation of the ASHA (Accredited Social Health Activist) programme in 2005 under the National Rural Health Mission (NRHM)

• Eligibility Criteria: ASHA must be a married, widowed, or divorced woman resident of the village, preferably aged 25-45 years.

• Educational Qualification: She should be literate, preferably with at least 10th standard education, though relaxations are allowed if no suitable candidates are available.

• Selection Process: ASHA is chosen through a rigorous selection process involving community groups, self-help groups, Anganwadi institutions, village health committees, and the Gram Sabha.

• Scale and Workforce: Comprises one million female health workers, making it the world’s largest community volunteer programme.

• Key Responsibilities: 

• ASHAs ensure the implementation of health schemes, provide maternal and child healthcare services, conduct immunisation drives, promote hygiene and sanitation.

• ASHA stores and distributes essential healthcare supplies like ORS, iron folic acid tablets, chloroquine, disposable delivery kits, oral pills, and condoms.

• Acts as a link between communities and the formal health system, ensuring last-mile delivery of healthcare services.

• COVID-19 Response: Played a critical role in vaccination drives, disease prevention, and community health awareness, ensuring healthcare access for rural and marginalised populations.

• Global Recognition: Awarded the WHO Global Health Leaders Award in 2022 for their significant contributions to public health and primary healthcare access.

• A PLOS Global Public Health study found that women connected with ASHAs are 1.6 times more likely to access maternal healthcare and institutional delivery.

The Triple Burden of ASHA Workers (Box)

• Home Responsibilities: As women, ASHAs are expected to fulfil their traditional domestic roles, including cooking, cleaning, childcare, and managing household responsibilities.

• Community Work: ASHAs are deeply involved in local healthcare delivery, conducting health awareness campaigns, assisting with vaccination drives, managing disease surveillance, and performing home visits.

• Institutional Work: They liaise with health centres, assist in hospital admissions, document health data, conduct surveys, and coordinate with government officials for implementing health schemes.

Due to these overlapping roles, ASHAs work long hours without adequate rest, pushing them into physical and mental exhaustion.

Issues Faced by ASHA Workers

• Lack of Formal Recognition: Despite being part of a state programme, ASHAs are classified as ‘volunteers,’ denying them labour rights like minimum wage, sick leave, and pensions.

• Heavy Workload Without Fair Compensation: Initially expected to work a few hours per week, ASHAs often work full days due to increased responsibilities, including surveys and documentation.

• Gendered Exploitation and Social Disadvantage: ASHAs, mostly from marginalised backgrounds, are seen as ‘natural caregivers,’ leading to systemic undervaluation of their labour.

• Low and Irregular Pay: 

• Their fixed monthly incentive is only ₹2,000, with additional earnings based on performance-based incentives, which are often lower than MGNREGA wages.

• Many ASHAs have faced non-payment of stipends since the pandemic, increasing their financial instability.

• ASHAs in Bhopal spent up to 63% of their income on job-related expenses, such as transport and mobile recharges, with no reimbursement.

• Lack of Social Security and Health Insurance: 

• ASHAs are excluded from the Code on Social Security 2020, despite recommendations from the Parliamentary Standing Committee on Labour.

• Unlike other government healthcare workers, they are excluded from the Central Government Health Scheme (CGHS).

• Severe Exploitation During the COVID-19 Pandemic: ASHAs worked 8-14 hours daily, including weekends, without protective gear, extra resources, or hazard pay.

• Weak Institutional Support: The rural healthcare system relies on ASHAs for critical service delivery but does not provide adequate training, resources, or recognition

• Health and Well-Being Concerns: 

• A significant proportion of ASHAs suffer from anaemia due to inadequate iron intake, overwork, and a lack of access to regular healthcare.

• Stress, lack of sleep, and continuous physical exertion contribute to diabetes, hypertension, and cardiovascular diseases among ASHA workers.

• 30% of ASHAs surveyed in Phanda, Bhopal, reported skipping breakfast; 13% do not eat all day.

• Social and Gender-Based Challenges

• ASHAs belong to marginalised communities (SC/ST groups) and face caste and gender hierarchies in the health system.

• Reports of abuse, harassment, and assault are underreported, with ASHAs lacking redressal mechanisms.

• Policy Gaps and Demands

• The 2011 National Health Systems Resource Centre report on ASHAs did not mention working conditions or systemic challenges.

• Interim Budget 2024 provided free health insurance under Ayushman Bharat for ASHAs, but implementation gaps exist.

Recent Strikes (Box)

• Kerala: ASHA workers have been currently on strike for over a month, demanding an increased honorarium of ₹21,000 per month and a ₹5 lakh retirement benefit. The protest was triggered by irregular payments, as their current ₹7,000 honorarium remains below the state's minimum wage for unskilled labour.

• Odisha: ASHA workers in Odisha began their protest on March 10, demanding a fixed salary of ₹10,000, an additional ₹3,000 for facilitators, government employee status, timely incentives, and social security. With no consensus reached in talks, they announced an indefinite strike.

• Karnataka: ASHA workers ended their strike in January 2025 after the government announced a fixed honorarium of ₹10,000 per month from April, along with incentives, three months of paid medical leave, and monthly leaves. The government also promised to review retirement compensation and involve workers in pre-budget discussions.

CONCLUSION