Sarabjit Kaur, Editor, Inspire Spectrum

Recently, ASHA (Accredited Social Health Activist) workers have been awarded the Global Health Leaders Award-2022 for being at the forefront of healthcare delivery in India. “ASHA (which means hope in Hindi) are more than 1 million female volunteers in India, honoured for the crucial role in linking the community with the health system, to ensure those living in rural poverty can access primary healthcare services, as shown throughout the Covid-19 pandemic,” said a release from the World Health Organisation (WHO). ASHAs were one of the six recipients of the WHO’s Global Health Leaders Award-2022 that recognises leadership, contributions to advancing global health and commitment to regional health issues.

ASHAs were introduced under the National Rural Health Mission in 2005 for providing maternal care, immunisation for children and community health care in every village of the country. During the pandemic, the workers were tasked with spreading awareness about COVID-19 and safety protocols, identifying and tracking COVID-19 positive cases as well as carrying out vaccination drives, often without any personal safety gear.

Unfortunately, the accolades and laurels cannot feed empty stomachs. ASHA workers have been demanding payment of minimum wages, social security benefits and pension without any success. They only get a monthly honorarium of ₹2,000 per month from the Centre, and some State governments offer an additional amount. During COVID-19, the Centre offered an additional ₹1,000. Such a meagre amount after scores of ASHA workers sacrificed their lives succumbing to COVID-19! To top it, their families are yet to receive the ₹50 lakh compensation for death due to COVID-19 for frontline workers.

Arguably, the lack of adequate spending by the Central Government and, consequently, state governments, is in part attributable to the abysmally low budgetary allocation to healthcare in India. The latest Union Budget 2021-22 considered health allocation primarily on the basis of COVID-19 mitigation but failed to allocate sufficient funds to public health schemes.

ASHA workers often work for long hours, sometimes all seven days a week, on par with (or exceeding) workers in other sectors who not only receive salaries in line with minimum wage requirements, but are also eligible for various statutory benefits. The performance-based incentives paid to ASHAs are also insufficient, often paid in a delayed manner. Further, the targeted hiring of only women as ASHAs, especially with the launch of the Reproductive and Child Health Programme in 1997, has perpetuated the stereotype that their healthcare work is ‘women’s work’. As largely disadvantaged women performing ‘voluntary’ labour, their entitlements and problems have not been taken seriously.

India’s ASHA programme not only undervalues workers but exacerbates their social vulnerability, adding layers of discrimination while failing to provide workplace safety, pensions, or other stability-promoting interventions. The State has failed to take proactive steps to provide decent livelihood, address stigma, violence and discrimination against ASHA workers. Policy makers argue that a fixed salary can lead to complacency in the worker’s approach as opposed to an incentive-based system that ensures accountability. Noting that administrative and monitoring structures in rural areas are already ‘strained’ and “struggling to ensure the selection, retention and performance of existing frontline workers”, policy makers hypothesised that guaranteeing ASHA workers’ salaries would result in them underperforming – like Anganwadi workers and frontline nurse – midwives.

Studies have evidenced the systematic practice of devaluing female labour. Women have always been and still are systematically stereotyped as ‘soft skill’ service providers in the healthcare sector. The undervaluing of women’s social care and health jobs relates to wider norms and attitudes in society, where women’s skills are often less visible than men’s and accordingly considered hard to quantify especially when linked to productivity – it is seen that women are stereotyped as being naturally good at the job and are thought to be prepared to trade lower pay for job reward.

The ASHA programme takes advantage of the social and economic marginalisation of women, asking them to do a lot of work for below liveable wages. Since 2005, ASHAs have contributed to healthcare service delivery to the most marginalised communities, promoting vital services for reproductive health, family planning and skilled care for childbirth. In the current COVID-19 pandemic that brought the whole country to a near halt, ASHAs significantly contributed to the management of the pandemic. The access of ASHAs to full and proper realisation of their fundamental rights is critical to their entitlements as persons and workers, and to public health across the country. Amidst the recent WHO clarification, we hope that the plight of ASHA workers gets a fair hearing by the Centre and the states.