The Story of ASHA Workers
Between 7 to 9 August this year, over 600,000 ASHAs went on a strike. They demanded better pay, medical protection, regular COVID-19 testing, and the status of government employees.
Words by Saumya Kalia
September 13, 2020
Illustration by Aarman Roy
The old bus station in Radaur, a village east of Kurukshetra in Haryana, is a fixture of everyday life that finds its popularity subdued during the pandemic. But the heat wave of August carries potential to break its dormant impulse.
In the shadow of a banyan tree, sit 20 women in hues of pink and red. Some wear surgical masks, others have their faces draped with dupattas. The ground behind the station continues to hold this spectre for some days to come.
Leading them is Surekha, general secretary of the Accredited Social Health Activist (ASHA) Union in Haryana. Her association with the Union goes back to its inception in 2009, when she first began guarding the picket lines for the 20,000 ASHAs in her state.
“Sarkari karmacharee ka darzo do, (Give us the status of government employees)” her voice rings in the air. “Darzo do, darzo do,” say women in follow-up to her revolt.
In the national capital, a similar congregation sits at Jantar Mantar. The site has witnessed dissent in all shapes and forms – it is only befitting then that almost 6,000 ASHAs of New Delhi assemble here for recognition.
The ASHAs are ferocious women. They helped in eradicating polio, reducing maternal mortality, and expanding vaccination coverage. Now, as the country’s COVID-19 outbreak pushes them to a breaking point, they are cementing their resistance.
Between 7 to 9 August this year, over 600,000 ASHAs went on a strike alongside other trade unions in India. They demanded better pay, medical protection, regular COVID-19 testing, and the status of government employees. As shadow workers, ASHAs have emerged to be India’s national pride – and shame.
On a worn-down wall in Santosh’s one-bedroom shanty, hangs a calendar turned to August 2020. It could be any day, week, or month – she wouldn’t notice. For the 44-year-old in Haryana’s Bhamniwala village, every day begins at 4:30 am and later blends into frenzy. She assiduously wades through household chores before venturing out the door armed with a diary clad in a pink suit-salwar. During the pandemic, a make-shift mask makes its way into her arsenal.
The colour pink has long symbolized the Accredited Social Health Activist (ASHA).. Globally, she and one million other women form the world’s largest all-female community health worker programme (CHW).
ASHAs offer a much-needed recourse to the public healthcare system, which is in itself an exposed flank characterised by lack of funds and staff. For every 1,800 people in India, there is one doctor and roughly two nurses. Since 2005, ASHAs have been entrusted with bridging the knowledge gap between people in rural areas and urban slums – where 65 percent of the country’s population resides – of healthcare policies. As these women uphold a waning system, their identity becomes inextricably tied to being an ASHA.
Santosh has worked as an ASHA for 15 years, and today heralds trust among the 1,950 people in her community. The high degree of reverence and acceptability ASHAs come to enjoy binds them closer to their role as a leader and caretaker, a source of pride for many women in pink. Being an ASHA is a social contract: work for the community, by the community. It is also this emotional connect that becomes the foundation of their work across populations who felt distant from government reach.
The role carries the promise of financial relief. A large portion of ASHAs are SCs, STs, and OBC, and range from poor to middle-income backgrounds. In some cases, ASHAs’ income supplements that of their husbands who work as farmers or tradesmen. It also grants economic security to widows. The programme transforms into an empowering avenue for women venturing beyond the domestic framework.
Santosh says how the maxim over the years has emerged to be one: rush whenever you’re called. Erratic work hours have become second nature to her work. On several occasions, she has helped with deliveries well past midnight.
The official module mentions a commitment of three-four hours per day, two-three times a week for ASHA volunteers. However, this materialises into significantly longer hours for most ASHAs. According to an International Labour Organisation (ILO) report, they were clocking in five-six hours almost every day of the week, which was considered to be a conservative estimation.
‘There is no time to breathe for ourselves,’ Santosh says, her voice sounding all too familiar with the exhaustion.
To call Santosh a worker would be an institutional snafu, a misnomer. The health system takes great pains to identify ASHAs as ‘volunteers’ to prevent organizing around minimum wages and job security.
In March, when the pandemic came knocking, ASHAs had to fold in a new identity of frontline workers. As first respondents, they became a critical source of information for organisations forming policies. Alongside screening and contact tracing, ASHAs keep a track of where community spread and clusters are, how many people have been tested, how many people are in home quarantine. The pandemic has further put their work hours into a tailspin.
As volunteers, they are compensated through performance-based payments. Each activity – like child delivery or immunisation drives – has a price tag attached to it. Over the years, ASHAs have pointed out the inherent flaw with this model of compensation: many women are forced to prioritise activities with higher incentives. They have swiftly unionised over the years and demanded a fixed honorarium separate from these bonuses. Different states have fixed different markers – Haryana agreed to pay Rs. 4000 per month while Karnataka pays Rs. 8,000. Yet, there exists a huge problem of back pay as ASHAs are forced to chase authorities for late payments.
To add to their woes is their technological struggle with ASHA-Soft, the application for logging their work. The government has rallied towards digitising grass roots operations but it remains inaccessible. The idea of digital inclusivity holds little weight in a scenario where women are not allowed to own smartphones or if they are, receive no training on how to use them. Several ASHAs rely on other volunteers to log in their data for them.
The government’s response to their demands has come in a piece-meal fashion. In 2018, they agreed to double their fixed monthly honorarium from Rs. 1,000 following a nation-wide agitation. Other demands like logistical support, social security benefits, and smartphones were also agreed to after a month’s strike. But many of these are yet to be implemented.
Their increased workload during the pandemic has translated to a rapidly decreasing income. Time spent on immunisation and awareness activities has reduced due to COVID-19 tasks, rendering ASHAs unable to meet targets and claim linked incentives. The central government’s token sum of Rs 1,000 a month from January to June offered scant relief. It was seen to be disproportionate to their physical and emotional labour.
“The authorities don’t care what or how much we’re doing; they have attached a price to our job and lives which is a paltry sum of money,” says Santosh.
The insult to injury becomes more pronounced as they shell out money from personal savings to buy gloves and sanitisers or for travel costs. The work had intensified, the role had become essential, their lives were at risk. Till date, almost 20 ASHAs have succumbed to the disease.
The burgeoning workload compounded by the dangers of infection make it harder for ASHAs to justify their work to themselves and their families. Santosh mentions a woman ‘volunteer’ in her village who died by suicide last month. Her family had been pressuring her into quitting because it brought in only risk, not money.
The pandemic then becomes a fertile ground for breeding stigma and fear. Cases of them being attacked and beaten have become notoriously common, Surekha recounts. These women have been spat on and beaten because of their life-saving work. An ASHA in New Delhi tested positive in July and has since faced severe ostracisation and hostility. It has been two weeks since recovery, but the nearby grocery shop refuses to entertain her as a customer.
However, this is not an aberration. Over the years, Surekha has watched ASHAs being pushed to a corner by people, the system, and their own families.
When Santosh spends long hours on the field or has to rush for a delivery late at night, her resolve dwindles under the gaze of her family members. ASHAs have to explain their absence. Working long hours is seen as willful neglect of their “family duty”.
Moreover, their safety and mobility were threatened even prior to COVID-19. In 2016, after the gang-rape and death of an ASHA worker in Uttar Pradesh, a fact-finding report expounded the rampant gender and caste-based violence ASHAs face. Offenders are mostly from the same village or are men of influence. Restitution, then, is seldom chosen.
Popular perception of an ASHA is rooted in the notion that care work is inherent to women. As an all-female cadre, ASHAs are seen to be advantageously placed to tend to children and women’s reproductive health in a culturally-appropriate way.
To Surekha, this explanation holds little weight. She points out how this ‘advantageous placement’ is euphemistic of a ‘woman’s work’ in a patriarchal society. When perceived as an extension of household care work for the whole community, an ASHA worker’s toil becomes a social obligation. This provides little space for any conversation around her labour and its valuation. Professionally, they fight for their rights, respect, and recognition within the formal health system.
If it were 900,000 men in their place, would they receive the same treatment? Who is to say.
What explains the institutional qualms about regularising ASHAs? A simple answer would be that if ASHAs are integrated into the bureaucratic mould, it might jeopardise their acceptability in the community. Additionally, bureaucrats believe the channel of communication functions one way, with information trickling down to ASHAs instead of up from them.
The low investment in healthcare – which is currently less than 1.5 percent of the GDP – is another factor. In the 2020-21 budget allocation, the amount set aside was reduced by Rs. 390 crores as compared to last year. If ASHAs were to fall under the public sector, national or state governments would have to ensure selection and retention of one million women.
ASHAs have grown in importance as they shoulder challenging tasks in areas and work through life-saving situations. Initially, they were responsible for a 1000 people; a number that shot to 2000 spelling round-the-clock working hours for already overburdened women. Where volunteerism ends and official work begins no one can tell. The original vision for ASHAs then no longer remains tenable; the status quo demands to be rethought.
The pandemic has underscored the wisdom in respecting frontline workers. ASHAs have emerged to be a precious resource as they carry updated information to isolated parts. It is their rootedness in communities that has served them well.
Over 100 ASHAs who protested in the national capital on 9 August were arrested for violating health guidelines three days later. The glorified label of “Corona Warriors” has now begun to grate on many.
What do a million women, who connect remote parts of this country to healthcare, do when a system insists on deflating their worth? They fight on three fronts. They question the health system, they go against gender roles, and they impede the pandemic. Their movement dates much before the pandemic to almost 11 years ago when pink-clad women first unionised at a national scale. This fight ceases to be just their story. It becomes one of all women. Their fight comes at a critical juncture when labour protections across India are being diluted.
“We’ve come such a long way; we can’t give up now,” says Surekha. “We have faith in our resistance.” In her state of Haryana, ASHAs have announced an indefinite extension to the strike that started four weeks ago.
This isn’t their first frontier and won’t be their last. On this afternoon, their movement continues to live against all odds with protests going on in Punjab, Bihar, and Haryana.
SAUMYA KALIA is a writer based out of Delhi.