India’s response to the pandemic has depended heavily on the exploited labour of women workers, most of them from marginalised backgrounds. These are ASHAs  or Accredited Social Health Activists, the cadre of frontline health workers that has been mobilised for everything from door-to-door surveys, distributing medicine kits, measuring oxygen saturation, monitoring containment zones and spreading awareness about vaccines. 70,000 such women recently went on strike in Maharashtra demanding higher pay, regularisation of work and social protection. In August 2020 there was a nationwide strike of 6 lakh ASHAs, and over the past year there have been strikes and protests across States, including Karnataka, Madhya Pradesh, Haryana, Punjab, Gujarat and Kerala.

The extra burden of pandemic-related duties, lack of protective gear, harassment by the public and delayed payment of COVID honorariums have led to this breaking point, for workers who were already underpaid and overburdened. This has also prompted the National Human Rights Commission to ask the Centre and States to file reports on the poor working conditions of ASHAs. The existing policy framework for ASHAs, based on regressive classifications of women’s labour, does not support adequate compensation, and is in need of a complete overhaul.

ASHAs: volunteers or workers?

It was in 2005 that the government started deploying ASHAs under the National Rural Health Mission (NRHM). The Mission Document of the programme posited the role of the ASHA as a core strategy for improving access to healthcare at the level of rural households. There are currently a total of 10,47,324 ASHA workers across India.

NRHM guidelines state that an ASHA would be an ‘honorary volunteer’, not receive any salary and her work would not interfere with her ‘normal livelihood’. The ASHA’s workload was supposed to be just two-three hours, four days a week, along with some extra events. This categorisation is based on the premise that the work of an ASHA is just a supplement to the worker’s main livelihood. However it was seen that most ASHAs were working between 25-28 hours a week, and even beyond that. In 2020, it was found that because of additional pandemic duties, ASHA workers across India have been working an average of 8-14 hours a day in the field, including on weekends.

This characterisation of ASHAs as community volunteers or activists reflects the continued devaluation of women’s work, which is a widespread trend in low income countries. It also signals the government’s unwillingness to invest in a regular cadre of human resources for public health in rural areas as it would have long-term fiscal implications.

Given the categorisation of ‘volunteer’, neither the Union Government nor States have any legal obligation to pay ASHAs a minimum wage. ASHAs earn money through task-based incentives under the National Health Mission (NHM), which is funded in a ratio of 60:40 between the Centre and the States. There are over 60 tasks under the NHM for which States can set incentives for ASHAs. These range from Rs. 1 for distributing items to households such as ORS packets, condoms or sanitary napkins, to Rs. 5000 for facilitating treatment and support to a drug-resistant TB patient. In 2018, the Union Government doubled incentives for a certain set of routine and recurring ASHA activities from Rs. 1000 to Rs. 2000. An amount over and above the NHM resource envelope was offered to States for this purpose, although they were free not to use it.

Some States pay ASHAs a fixed monthly amount in addition to performance-based incentives. The scope and amount of incentives vary among States, therefore ASHA workers’ monthly earnings can differ widely. In spite of States supplementing the income of ASHA workers from their own budgets, the supplements do not amount to much when matched with the nature of tasks and the workload of ASHAs. For instance, Rajasthan and West Bengal pay a fixed minimum of around Rs. 3000. However even when combined with performance-based incentives, the ASHA’s average monthly earnings do not match the minimum wage for a highly skilled worker.[1]

Fragmented, incentive-based pay creates vulnerabilities

What an ASHA earns in a month also depends on the scope of carrying out different tasks. The most lucrative tasks are institutional deliveries under Janani Suraksha Yojana, ante-natal care, family planning and immunisation, as the demand and scope for these is greater than, say, follow-up visits for severely malnourished children or referring leprosy patients for treatment. Potential earnings from a task may be lowered if a State imposes conditionalities on the service. For example, Gujarat restricted the incentive for accompanying women for maternity services only to Below Poverty Line (BPL) women. Certain activities within activities may not be compensated at all, such as transport for ante-natal services.The incentive structure also makes ASHAs vulnerable to crisis situations. The drastic drop in child and maternal health services during the pandemic meant that ASHAs experienced a severe drop in earnings.

It is notable that there is no single budget head for ASHA incentives. As each incentive is tied to a different activity, they are drawn from various financing pools of NHM. Most ASHA incentives are funded out of the Reproductive and Child Health Flexi-pool, while the remaining are covered under Health Systems Strengthening, and pools for Communicable Diseases and Non-Communicable Diseases. One set of incentives is even budgeted under the Ministry of Drinking Water and Sanitation. In terms of programmatic components of NHM, ASHA incentives are approved under ‘Community Interventions’, whereas expenditure for all other NHM health staff (including increments, EPF and allowances) is booked and approved under the head of ‘Human Resources’. Therefore, in the planning process, remuneration for ASHAs is not considered separately; rather it follows the planning and budgeting considerations of multiple programmes.

As incentives are released from different financial pools, the receipt of payments by ASHAs may be irregular and delayed. It was found that ASHA incentives for controlling vector-borne diseases and for TB were delayed for as long as 3-4 years in Assam, Bihar and Jharkhand. Some States have made efforts to streamline payments. Odisha, for example, has introduced an integrated payment system under which incentives are transferred through DBT on a fixed day every month, and temporary loans can be availed in case funds are not available under a particular head.

The need for social protection and opportunities for growth

Not being classified as ‘employees’, ASHAs do not have access to formal frameworks of social protection. They instead have to rely on ad hoc, temporary welfare measures. In 2018, the Union Government made ASHAs eligible for life insurance, accident insurance and pension under the following schemes: Pradhan Mantri Jeevan Jyoti Beema Yojana, Pradhan Mantri Suraksha Beema Yojana, Pradhan Mantri Shram Yogi Maan Dhan. However, the free cover under these schemes appears to only have been provided for a period of one year. Several States have enrolled ASHAs under their own social security schemes.

Following the pandemic, an additional monthly incentive of Rs. 1000 was provisioned for ASHAs undertaking COVID-related activities, and they were also included for insurance cover under Pradhan Mantri Garib Kalyan Yojana. However, over 30 per cent of ASHAs claim they have not received the incentive amount, as reported in a study by BehanBox and Azim Premji University. Further, there was high variability among States in the number of months for which this additional incentive was provisioned.

In sum, these are temporary measures and do not guarantee social protection in the long term. Frontline workers, including ASHAs, have not been included in the new Code on Social Security, 2020, contrary to the recommendations of the Parliamentary Standing Committee on Labour.

In 2013, states were asked to identify ASHA workers who wanted to obtain class X or class XII qualifications, which would enable them to enrol in ANM or Nurses Training Schools, and fund their registration with NIOS. However, a 2018 review of the NHM shows limited progress. The number of ASHAs enrolled in career advancement avenues was very low across States: 1800 in Jharkhand, 120 in Maharashtra and 119 in Assam.

Towards progressive policies on women’s work

The poor status of female frontline workers in India reflects a regressive outlook towards women’s employment, particularly that of the most disadvantaged women. Workers like ASHAs do not have adequate opportunities for upskilling and improvement in pay, and they remain stuck in the informal economy, while continually being burdened with new areas of work. At the same time, the rate of women’s workforce participation in India remains low and has even declined in some areas, reflecting a lack of remunerative jobs.

ASHAs must be reclassified as employees, provided regular pay over and above the minimum wage, and commensurate with their nature of work, and be brought under long-term social protection. They must also be provided opportunities for specialising in specific areas of health, and for moving up to higher positions in the public health system.

[1] The average monthly earnings also fall far short of Rs. 18000 a month, the starting salary norm for Central Government employees as per the Seventh Pay Commission scale – which has been a longstanding demand of ASHA workers.

Author works with Centre for Budget and Governance Accountability (CBGA), New Delhi. Views expressed are of the author, and do not necessarily reflect the position of CBGA. You can reach her at shruti@cbgaindia.org.