The COVID-19 pandemic has put a spotlight on community health infrastructure—in particular, its various shortcomings, as countries across the globe struggle to ensure basic compliance with social distancing norms and implement effective contact tracing. A vital part of this infrastructure is the vast network of grassroot-level community health workers, volunteers working within their communities to conduct information campaigns, ensure compliance with immunisation schedules, provide prenatal and neonatal care etc.
In India, these functions are carried out by a network of more than 9,00,000 Accredited Social Health Activists, or ASHA. In the wake of the pandemic, their role has become all the more vital; most states have utilised them for contract tracing, spreading information about social distancing and masks through door-to-door visits, and identifying potential victims. However, this has also made their work all the more dangerous, by placing them at a higher risk of infection (health workers comprise of about 10% of global COVID-19 infections), and exposing them to outright harassment and violence. The very same communities that respected them as ‘Didis’ until a few months back, stigmatise them now as harbingers of the virus.
A Dismal Picture
What the pandemic has also brought to the fore is how thankless the job of the ASHAs is, as they remain severely underpaid and, in many cases, unpaid, even as they log more hours at work than other equivalent health workers. This has led to an eruption of protests by ASHA unions across the country, the most prominent being the 10-day strike by ASHAs in Karnataka. Their demands are the provision of Personal Protective Equipment—as reports of ASHA workers dying on the job pour in—and the promise of a fixed salary of Rs. 12,000 a month along with employment benefits, like regularised government employees. Workers in Delhi have followed suit, with similar demands.
While many of the issues raised by the ASHAs are specific to the pandemic, the dissatisfaction with the government’s treatment stretches further back. Back in January this year, more than 10,000 ASHA workers led a march in Bengaluru, to protest against the non-payment of their Rs. 3,500 honorarium for the preceding 15 months, claiming that only 20% of the state’s 40,000 workers are being paid regularly. Underpayment of the ASHAs is a structural issue that has to do with their legal employment status. With their enhanced role in the pandemic, the issue has only got aggravated.
Grassroot-level healthcare workers in India broadly fall into three categories: Auxiliary Nurse-Midwives (ANM), Anganwadi Workers (AWW), and ASHA. The ANM are trained for 2 years and are responsible directly for administering immunisation drives and delivering children. The AWW are trained for a few weeks and primarily serve as facilitators to the AMN, in differing capacities. Their role is more stationary as pre-school educators and workshop conductors, as compared to the ASHAs, who are mobile, a large part of their work involving home visits to teach pregnant women about neonatal care and to ensure institutional deliveries .
Since the inception of the program in 2005 under the National Rural Health Mission, the ASHAs have proved to be instrumental to the improvement of basic health outcomes in rural areas. Their impact on institutional deliveries, child immunisation, and prenatal care through information dissemination has been significant—with some studies concluding that immunisation rates have risen by 12-17% in some states—while their performance on other measures has been modest. Some studies also highlight concerns regarding irregularity of hospital visits and lack of access. Nonetheless, the ASHAs remain indispensable to our country’s health system.
An Honorarium Difficult to Honour
Apart from their function, the three classes of workers differ in their legal status, which in turn impacts their remuneration. While ANMs are formal government employees who receive upwards of Rs. 20,000 per month, alongside other employment benefits like paid leave, insurance, and maternity benefits, the AWWs and ASHAs are considered volunteers. Thus, they receive an ‘honorarium’ instead of a fixed salary. ASHA workers also have an incentive-based system, where specific tasks, like organising meetings or maintaining village registers, earn them an amount ranging from Rs. 150 to Rs. 300 per task, with additional incentives that differ by state.
However, given their volunteer status, their earnings are still paltry—the honorarium ranges from Rs. 2,000-4,000 depending on the State/Union Territory, apart from the central government incentive system. As recently as 2018, the amount ASHAs could earn from this incentive system was only Rs. 1,000-1,500 per month, which was raised to Rs. 2,000. That still adds up to about Rs. 6,000 only, well below the minimum wage of Rs. 18,000 suggested in the 7th Pay Commission for skilled workers. Moreover, they are required to perform a host of other tasks that they are not paid for. They are also underpaid in comparison to AWWs, who earn Rs. 10,000 or more in states like Haryana, Kerala, and Telangana. Given the relatively riskier nature of their work and general neglect by the state, the plight of the ASHAs have been foregrounded in the COVID-19 crisis.
The Role of Gender
To contextualise the woes of the ASHAs and their neglect in policy frameworks, an important aspect to consider is gender. Globally, 70% of all health workers are women, but they occupy a disproportionately low 25% of senior, managerial positions. The situation in India is even more skewed, as ASHAs, AWWs, and ANMs are almost exclusively women (since their work demands close contact with women and children, men may simply not be as effective). The implication is that administrators are often not sensitive to the workers’ concerns, and governments fail to account for the various challenges that they face on account of their gender.
Before the pandemic, ASHAs often faced the disapproval of their family members for travelling outside in the night, to facilitate an institutional delivery, for instance—so much so, that some ASHAs take their husbands with them on such night visits. Moreover, their household responsibilities, alongside this stigma, impinge on their ability to travel far from their homes, impacting the access of remote households to their services. The guidelines themselves require ASHA workers to be married, as unmarried women often face even greater restrictions on their mobility.
In the wake of the pandemic, other issues too have cropped up, even as pre-existing problems stand amplified. ASHAs now work for longer hours and travel farther distances to monitor potential infections, putting them at risk of greater hostility in their own homes. In the absence of protective equipment, they often distance themselves from their family members, hindering their ability to fulfill household responsibilities. The expansion of their work beyond women and child health has put them in greater contact with men, adding to their pressures—in Kozhikode, a group of men damaged an ASHA’s scooter since she’d asked them to follow social distancing norms. They, reportedly, did not want to listen to a woman.
The Government’s Response
While governments have been quick to enlist the ASHAs for preventing the spread of the virus, the response to their concerns and demands is dismal. The centre announced a meagre sum of Rs. 1,000 in addition to the monthly honorarium as compensation for COVID-19 related tasks. This, even as most ASHAs stand to lose out on their incentive-based income since they lack the time and resources to continue with their usual duties. Most ASHA workers are yet to receive this amount.
Moreover, beyond a directive issued by the Central Government dated 20 April instructing all state governments to provide ASHAs with protective gear, there have been no concrete steps to actually effect this. Even states with greater healthcare spending relative to others, like Kerala, have failed in this regard. The Centre also brought in an ordinance to amend the Epidemic Diseases Act, 1897, making attacks on healthcare workers non-bailable offences, punishable with a fine of up to Rs. 5 Lakhs and imprisonment for 7 years. However, it is difficult to say how effective a punitive, legal solution would be in improving working conditions for ASHAs on the ground, when the problem seems more acute.
The Way Forward
While the demand for a fixed minimum wage, ranging variously from Rs. 12,000 to Rs. 18,000, has become increasingly ubiquitous among ASHA unions across the country, the welfare impact of such a change seems ambiguous. Although the benefits accruing to the ASHAs are obvious, a fixed salary would imply doing away with incentives. This might have an adverse impact on health outcomes, since the incentive-based system currently in place is a major force beyond some of the successes of the ASHA programme, like increased immunisation and institutional deliveries. Any change in the remuneration structure should incorporate a moderate minimum wage with higher incentive amounts, such that foregoing them becomes costlier. Alternatively, policymakers may need to devise other structures for compliance, if a fixed salary is implemented. Neither of these changes is possible without a substantial increment in public health expenditure.
Apart from this allocative aspect, what is also due is a fundamental restructuring of the mechanisms for monitoring and managing ASHAs, such that the system is sensitised to the gendered problems faced by ASHAs in particular and community health workers in general. This would require hiring more women in managerial positions, as well as a change in guidelines and worker contracts, keeping in mind the specific constraints faced by ASHAs as women.
Adit Shankar is a graduate in Economics from Ashoka University, returning for the Ashoka Scholar’s Programme.