On May 22, India’s Accredited Social Health Activist, or ASHA, workers received the World Health Organization’s Global Health Leaders Award. They joined five other recipients in recognition of their “contributions to advancing global health, and demonstrated leadership and commitment to regional health issues.” The award was also posthumously given to eight volunteer polio workers in Afghanistan who were shot and killed by gunmen in the Takhar and Kunduz provinces in February.
Against the backdrop of the 75th World Health Assembly, the WHO announced that India’s ASHA workers had been honored for their “crucial role in linking the community with the health system, and ensuring that those living in rural poverty can access primary health care services.” First established under the National Rural Health Mission (NRHM) in 2005, over one million women across India are working as ASHAs. They serve as key intermediaries, and often the first point of contact, between marginalized and vulnerable communities and the healthcare system. Chosen from within the local community, ASHA workers perform around 60 tasks, related to reproductive health, child nutrition, and immunization. They also provide basic preventative and curative care including therapies and medicines. Despite forming the backbone of the public healthcare system, ASHAs are not recognized as workers. Rather, they are classified as “honorary volunteers” and are only entitled to incentives on a task-by-task basis. ASHA workers are given monthly honorariums in some States, however the amount can be as low as Rs. 2,000 ($25.8). For completing the immunization of a child under the age of one, an ASHA worker is paid Rs. 100 ($1.29). These insufficient payments are often delayed, leaving already vulnerable women scrambling to make ends meet.
In this context, the WHO’s award “is not only a recognition of the work done by ASHA workers, it is a recognition of the necessity of that work, not only in India but also in other Third World countries where health systems are in need. In such instances, community-based health work is crucial. This [award] is a recognition of the dedicated and selfless work being done by such workers,” says AR Sindhu, National Secretary of the Center of Indian Trade Unions.
A second question that emerges, Sindhu argues, is whether the work being done by ASHA workers is even considered as such. “The question here is of unpaid care work, where the [Indian] government itself is the biggest exploiter of the unpaid work of women in India. As such, our first demand is that the government recognize this work [of ASHAs] as a basic service and a right of the people, and of ASHAs as workers.”
ASHAs and other government scheme workers have been demanding the regularization of their employment for years, to ensure access to a minimum wage, social security, and benefits including pensions. These demands became even more urgent with the spread of COVID-19 across India. On top of their routine duties, ASHA workers were placed on the frontlines of the government’s pandemic response. They were tasked with going door-to-door in containment zones to screen people for possible infections, and then get them tested. ASHAs also had to take affected people to quarantine centers, or assist them with home quarantine. Women were working upto 14 hours a day, seven days a week, without access to proper protective gear. A 2020 survey by Oxfam of ASHAs in four States revealed that 25% of workers had not received masks. Only 23% had received hazmat suits and only 62% had received gloves.
Not only has the work of ASHAs been invisibilized, the workers have not been provided with proper identification designating them as health personnel. This led to numerous instances where ASHAs were beaten up by the police for being out in the streets during the lockdown. They also faced harassment in the communities they were serving “because of the fear of COVID-19, people were treating them as COVID carriers, not COVID Warriors (a term used to denote essential frontline workers).”
The Indian government has not revealed the number of ASHA workers who have lost their lives during the pandemic. According to reports in 2021, the state had announced that 100 ASHA workers had died due to COVID-related duties. However, these figures did not account for the second wave which devastated India in April and May of last year. Back in March 2020, the government of Prime Minister Narendra Modi announced an insurance of Rs. 50 lakh ($68,000) to the families of health workers who died on the frontlines. In the over two years since, ASHAs have repeatedly stated that the funds have not been disbursed to the families of the victims. “Maybe less than 10 people all over India received the promised 50 lakh compensation. Some have received only 5 or 6 lakhs,” says Sindhu.
Moreover, the Rs. 1,000 per month ($12.9) announced as a COVID-19 risk allowance was also discontinued. Sindhu argues, “What is happening now is that COVID incentives have been stopped, while the pandemic-related duties have not.” Faced with government apathy and abandonment, ASHA workers have been consistently mobilizing at the local, State, and national level to secure their basic rights. They have been part of five countrywide labor actions during the pandemic – these include two national strikes by scheme workers, two massive general strikes by hundreds of millions of workers across sectors, and one strike by ASHA workers alone. Struggles have also been ongoing at the State level, including recent protest and strike actions in Haryana and Bihar.
The CITU-affiliated All India Coordination Committee of ASHA Workers has been demanding that the government implement the recommendations made by the 45th Indian Labor Conference. These include the regularization of scheme-based workers like ASHAs, a minimum wage of at least Rs. 21,000 and a pension of Rs. 10,000 per month. In a landmark decision on April 25, the Indian Supreme Court ruled that women working in Anganwadi, or rural child care centers, were entitled to gratuity. Similar to ASHAs, 2.5 million women are working as Anganwadi workers and helpers under the Integrated Child Development Scheme, taking care of the nutritional requirements of 158 million children in India.
“The direction in which the current government is headed is that of total privatization of the entire health system. We’re seeing it with the emergence of things like insurance-based healthcare,” Sindhu added. “If the government is still not ready to ensure the rights of the workers, we will be forced to intensify our struggle in the coming days.” An all-India protest action is set to take place in July to reiterate these demands.