The state of ASHA workers in India

 - Ria Nisar and Emma Salem

Who are India’s ASHA workers? And what are their roles and responsibilities?

An accredited social health activist (ASHA) is a community health worker instituted by the Ministry of Health and Family Welfare as a part of India's National Rural Health Mission. The Indian MoHFW describes them as ‘’health activist(s) in the community who will create awareness on health and its social determinants and mobilize the community towards local health planning and increased utilization and accountability of the existing health services.’’ The mission started in 2005, and full implementation of the same began in 2012. The long term goal is to have an ASHA in every village in India. There are about 9 lakh ASHA workers operating in the country currently. The role of an ASHA is that of a community level care provider. This includes a mix of tasks: serve as a key communication mechanism between the healthcare system and rural populations and build awareness about health care entitlements especially amongst the poor and marginalized. In the past they have undertaken various activities like motivating women to give birth in hospitals, bringing children to immunization clinics, encouraging family planning (e.g., surgical sterilization) and much more.

An ASHA worker is typically a female resident of the village she is residing in and who’s preferably between the age of 25 - 45 years.  ASHA’s preference for selection is that they must have qualified up to the tenth grade. Selected and accountable by the Gram Panchayat (local government body), these rules are relaxed if a suitable candidate isn’t found. She is primarily an “honorary volunteer” but is compensated for her time in specific situations (such as training attendance, monthly reviews and other meetings). In addition she is eligible for incentives offered under various national health programmes. She would also have income from social marketing of certain healthcare products like condoms, contraceptive pills, sanitary napkins etc. Supposedly, ASHA workers are required to work for only two to three hours about 4 days a week and they are supposed to have a flexible work schedule. 

The hardships faced by ASHA workers 

Although ASHA work is semi-voluntary, the staff are paid based on the tasks that they perform. In other words, it is all work, and very little pay. On an average, the performance-based incentive ranges from ₹5,000-₹6,000 a month. Many ASHA workers have faced exploitation, especially with regards to payment. During October 2020, in the midst of the pandemic, hundreds of ASHA workers were awaiting their payment for over 3 months, with the only reason being “insufficient funds” from the authorities. Many still continue their fight for better pay, and still battle with being paid on time. “We have been working as Asha workers for 13 years without a pay hike. Prior to that, we were paid nothing and started getting ₹1,000 much later”, adds a loyal ASHA worker, who experiences the same overworked and underpaid position in this line of duty. More recently, within the past 2 months, ASHA workers have been protesting for better wages, and a fixed incentive of ₹15,000 a month alongside social security benefits. In September 2021, ASHAs threatened to go on an indefinite strike if their requests were not met. Although these demands are not extortionate or unreasonable for the work ASHAs do, their journey towards better pay still continues. Amartya Sen in his book ‘Development as Freedom’ highlights the different kinds of freedom. Sen argues that there are five types of interrelated freedoms, namely, political freedom, economic facilities, social opportunities, transparency and security. Unfortunately, none of these apply to the ASHAs. In life, freedom is integral as it leads to enhanced expressions of creativity and original thought, increased productivity, and an overall high quality of life. The ASHAs who have been vulnerable to discrimination, irregular and unstable pay, lack of family support, verbal and physical abuse in some parts of the country, absence of technological equipment such as a basic phone to do their job and relentless denial on the part of the administration to frame and implement policies for their benefit, have been deprived of all kinds of freedom. Therefore, according to Sen, ASHAs fall in the category of having unfreedom (a lack of, or no freedom). 

 

ASHA workers’ involvement during COVID pandemic and the stress involved 

Covid-19, a global pandemic that changed everyone’s lives, has had a profound impact on ASHA workers in India, too. ASHA workers have been heralded as ‘Covid warriors’ during this time, as they have worked tirelessly to prevent spreading the virus, and to raise awareness of it. Not only have they had to deal with the pressures and new responsibilities surrounding Covid, ASHA workers simultaneously have to ensure their other duties and health services remain uninterrupted. A survey found that 29% of ASHA workers were working more than 8 hours a day, whilst the remainder of the respondents were working between 6-8 hours a day. This highlights the stress and long hours ASHA workers face, especially during the pandemic. ASHA workers were placed directly on the frontline, as their duties included Covid-19 testing, administering vaccines against the virus and checking on patients who were in quarantine. Shockingly, only 75% of ASHA workers were given masks, 62% were given gloves and a meagre 23% of workers have received hazmat suits. These statistics indicate that over a quarter of ASHAs were not given proper protection whilst they conduct their duties, leaving them vulnerable to contracting Covid. As a result of this, many ASHA workers had to pay for gloves, masks and hand sanitizers with their own money, despite being just as crucial as other frontline workers, such as doctors, during this turbulent time. Consequently, in the state of Karnataka, 16 ASHA workers have died since the pandemic in March 2020, all due to Covid. According to the ASHA workers’ union, the Covid death toll is predicted to be extortionately higher than the official account stated, without any proper acknowledgement from the state government. Due to ASHAs being exposed to the virus, many have experienced discrimination, and even violence, as a result of working with Covid patients. A survey shows that 33% of ASHA workers were subjected to some form of prejudice or harassment whilst they were performing their responsibilities, and many have found they are treated as a pariah throughout this time, even by their own family. Moreover, the Narendra Modi government has announced an insurance scheme to protect healthcare workers in Covid times under the aegis of Pradhan Mantri Garib Kalyan Yojana. The scheme provides an insurance cover of ₹50 lakh per person to frontline healthcare workers; sanitation staff, paramedics and nurses, ASHA workers and doctors. However, the survey reveals that only 38% of ASHA workers knew about the scheme. The underpaid and overworked ASHA workers, an indispensable part of India’s fight against the virus, have once again been subject to the malicious schemes of the Government.

 

The mental health of ASHA workers : A Case Study

Have you ever felt ‘burnt out’ from social pressures or responsibilities? According to official guidelines, the term ‘burnout’ is the most common mental health problem frontline workers, such as ASHAs, experience. This refers to feelings of emotional and physical exhaustion, depersonalization and mental strain. This can stem from the long hours ASHAs work and insufficient rest or access to food. As mentioned before, the lack of safety essentials needed for protection against Covid, and the hostility experienced from community members, have left ASHAs in a state of mental distress. “I have been having suicidal thoughts lately. The government officials didn’t just snatch my work but my dignity too. Apart from this, they created a sense of fear amongst other ASHA workers that no one is ready to take a stand for me. I have had enough of the abuse and don’t know what to do anymore to save my honor,” lamented Anju Bala. Bala is sadly not the only ASHA worker to feel this way. These depressive and suicidal thoughts are common in this line of work. ASHAs are not only subject to the maltreatment of the government, they are exposed to the harassment of locals and members from their own community, too. On top of this, they are also more susceptible to contracting Covid, and live in fear of dying from the virus. Havovi Hyderabadwalla, a clinical and forensic psychologist, discusses how ASHA workers mental health is affected by the nature of their work: “ASHA workers largely go through a lot of depression, anxiety and Post Traumatic Stress Disorder (PTSD) and these issues don’t just get triggered at work, the sufferer takes them home as well”. ASHA workers go severely undervalued, unnoticed and unappreciated; it is no surprise that mental health issues surface regularly. However, due to the lack of awareness surrounding mental health, and the scarcity of available help to treat mental disorders, the problem will only continue, and perhaps worsen for ASHA workers, if issues are not resolved.

 

Interview: of an ASHA worker and her experience 

After conducting a short interview with Anusaya, an ASHA worker from Delhi, it is clear to see the hardships and challenges ASHA workers face on a daily basis. When Anusaya began working as an ASHA a few years ago, her roles and responsibilities only included working 2 or 3 hours a day for 4 days a week. As mentioned earlier, this has dramatically tripled for ASHA workers, completely throwing off their work/life balance. Anusaya often finds herself working until 12 or 1am in the early morning, which is hardly conducive for a good night sleep. Sunday is typically a day off for Anusaya, however, this day off only refers to her ASHA worker roles; she must also perform her second job; housework. For a woman in India, especially those from marginalized groups in society, days off do not exist. These constant pressures and struggles ranging from financial insecurities, ASHA worker tasks to domestic chores cannot be beneficial for our mental health. Psychologist Hyderabadwalla  notes, “One can still cope with physical ailment if their mental faculties are together whereas if one, figuratively, loses their mind, they lose everything”. Hyderabadwalla highlights that maintaining a healthy mentality is paramount, especially for frontline workers, such as ASHAs. Additionally, Anusaya stated her monthly salary is around ₹3,000 a month, which converts to approximately $40 USD. However, this ₹3,000 a month can only be obtained once the ASHA has reached 6 points, as the government follows a point system for their remuneration. Typically, ASHAs have to reach 11 points in a month, and if one can only achieve 5 points, the ASHA will receive an insufficient amount of ₹500. This is alarming for many reasons; not only is this insulting to the hard work performed by ASHAs, but this barely covers any monthly living costs. Studies have shown that on average, for a family of four, their estimated monthly costs are ₹23,922 ($319 USD), not including rent. Anusaya also shared some personal experiences of maltreatment in the workplace. She found that when she was placed in a hospital, she was not treated as an equal counterpart to other hospital staff; she was treated unfairly and forced to do routine, mundane tasks. It is no surprise that Anusaya stresses the importance of seeing an increase in pay, less workload and more recognition and appreciation. These findings help us understand the continuous struggles ASHA workers face, and the changes that need to happen immediately.  

 

Further actions needed 

Immediate involvement from the government is required in order to relieve ASHA workers from stress, feelings of being burnt out and depressive or suicidal feelings. The government must begin mental health screenings for ASHAs, in order to see if they are suffering from any mental health issues, and provide the necessary treatment and support when needed. Thus, ASHAs desperately require mental health support from the government, and the discourse surrounding mental health needs to gain momentum in order for change to happen in India. Moreover, many ASHA workers feel their work is massively devalued in the public healthcare system, especially as ASHA workers are women, they automatically fall into the lower realms of society’s hierarchy. Their labor and responsibilities become labelled as emotional or feminized care work, denying them a professional status, or acknowledgment. The devaluation of care work, such as classifying it as “poor women’s work”, can be hugely damaging for ASHA workers’ mental health, and encourages female oppression; women must only be defined by domesticity. Change within society, and the government must take place. The government needs to reclassify ASHA workers as employers in order to help resolve the larger issue of devaluing women’s work, and for ASHAs to gain acknowledgement for their contributions. The subjugation and oppression of women has been, and still is, an ever-present part of a woman’s life in India. India’s ranking in the Global Gender Gap Report declined from 108th in 2018 to 112th in 2020, highlighting this urgent need for equal gender rights. Society has instilled patriarchy into our everyday lives, and in our social and professional spheres. It is imperative that the state and government pay more attention to the human and social development in India, including female empowerment, for things to change. It won’t be until women are viewed as equal counterparts to men, in all aspects of life, that ASHA workers will receive in full all of the social security benefits, fixed income and recognition in the healthcare field that they deserve. 

 

“Empowering women is key to building a future we want.” - Amartya Sen