The Government of India appears to be exceptionally good at two things – public relations and image management. On March 22, 2020, people gathered in their balconies and outside their houses across the country for the “thaali bajao”, a utensil banging even whose call was given by the Prime Minister in support of frontline workers. In his address, Narendra Modi called it a show of appreciation for “boosting” the morale of corona warriors.
One section that appeared to have been completely left out during for this grand event was Accredited Social Health Activists (ASHA workers), who have been leading an aggressive fight against Covid-19 in India’s remotest of locations. They are central to our national Covid-19 containment strategy. Ironically, they have been excluded from larger conversations, apparently because of their their “voluntary” status.
ASHA workers have made their mark (even before the outbreak of the pandemic) as a force that keeps our ailing primary healthcare system alive. The backbone of primary and natal healthcare of a country of 1.3 billion people is formed mainly by this group of volunteers. It is their mobility and access to communities that enable our government to ensure last-mile healthcare delivery.
ASHA workers have, throughout this pandemic, not just been actively working on contact tracing, providing supplements to and arranging logistics for those that are most vulnerable - but have also been performing their “regular” tasks. Immunization programmes continue. Women are still having babies and need ASHAs to assist them.
As per government “orders”, ASHA workers are expected to survey entire communities and fastidiously log details of these inhabitants. These orders prescribe a limit of 25 households a day. A senior office bearer of of the ASHA workers’ union in Haryana, however, complains, district-level pressure and the sheer volume of households has ASHA workers often surveying upwards of 100 households a day.
The cherry on this free labour cake, however, is that they are expected to do all of this without the safety of personal protective equipment (PPE). Despite repeated requests to department officers, ASHAs are not even granted the most basic of supplies (sanitisers, masks) when their core job is to interact and survey scores of people, some of whom are likely Covid-19 positive. These “health workers”, expected to risk their lives for “serving” larger cause, are allowed to become health hazards – to communities, to themselves and their own families.
“We have been raising the demand for regularisation of ASHA workers for years now. COVID-19 has only added to our woes. Since March, most of us have been working for more than 10 hours a day, with no increase in honorarium. If anything, the list of unpaid tasks has grown”, said a Haryana ASHA workers’ leader.
“The pandemic has subjected us to added burden from both ends. On one hand, community surveillance and contact tracing demanded extra hours at work, while on the other hand, household chores increased because our husbands and kids were at home for most of the day”, added another ASHA leader.
Put in a situation where they were given a shovel and asked to build a dam, the woes of ASHA workers extend beyond the general disregard for their well being. They were (and are) expected to navigate this maze of information and work with people without any data or direction.
They are required to download applications that provide them with survey resources, but with low tech literacy and the lack of smartphones, most had to resort to purchasing ones themselves, borrowing ones, or left to wade through the byzantine systems with no help and mounting expectations. In 2018, the Haryana government claimed that they would be issued Android phones to bring them into the digital workforce for better penetration and connectivity – a claim is still yet to be realized.
Working with rigid and apathetic officers, ASHA workers face heavy discrimination, violence, and active boycotts by residents. Most of them come from socio-economically disadvantaged backgrounds. In multiple incidents across the country, upper-caste households refuse to be surveyed by ASHA workers, objecting to quarantine sticker posters outside their doors. Often victims of violent attacks, the stigma faced by ASHA workers extends to their families. There have been reports of ostracization as also death and rape threats.
In Haryana, ASHA workers were asked by district collectors to man public distribution (PDS) stores, assist police screening, and generate other ad-hoc reports. Refusal to do this work invokes penalties and “explanation letters” followed by arbitrary incentive cuts. These “incentives” are what is offered for their voluntary service – amounts that are paid upon completion of tasks – tasks specific to their “healthcare worker” profile.
This incentive has been fixed at a mere Rs 1,000 per month by the Central government. The Haryana government stated that they would pay an additional 50%, bringing the amount to Rs. 1500, only to have that budget rolled back. The incentive is supposed be based on outcomes. With no standardization, the tasks they are asked to perform under the “outcome-based payment” are changed at the whims of department officers.
Lack of formal recognition as public health workers has led to loss of their legitimacy. Public health advocate Anant Bhan said, “ASHAs (and other community health workers) are structurally vulnerable to intimidation because they are perceived to have low status – they are female, at the base of the hierarchical health system, often not rich, not formally employed by the health establishment and are not salaried workers.”
On March 26, Union finance minister Nirmala Sitharaman announced a medical insurance cover of Rs 50 lakh per person for frontline health workers such as sanitation staff, paramedics and nurses, ASHA workers, and doctors. However, an ASHA worker told us a heart-wrenching story that points to the inefficacy of this tokenistic announcement.
In Rohtak, Haryana, an ASHA worker got infected with coronavirus in the line of her work. Her husband who had respiratory problems got infected as well and passed away. However, the cries of her family, as well as her other ASHA colleagues, fell on deaf ears and the health department refused to come to her aid. “Samaaj itna nirdayi kaise ho sakta hai? (How can society be so inhumane)”, she lamented with a cracking voice.
Working with rigid and apathetic officers, ASHA workers face heavy discrimination, violence, and active boycotts by residents. Most of them come from socio-economically disadvantaged backgrounds. In multiple incidents across the country, upper-caste households refuse to be surveyed by ASHA workers, objecting to quarantine sticker posters outside their doors. Often victims of violent attacks, the stigma faced by ASHA workers extends to their families. There have been reports of ostracization as also death and rape threats.
In Haryana, ASHA workers were asked by district collectors to man public distribution (PDS) stores, assist police screening, and generate other ad-hoc reports. Refusal to do this work invokes penalties and “explanation letters” followed by arbitrary incentive cuts. These “incentives” are what is offered for their voluntary service – amounts that are paid upon completion of tasks – tasks specific to their “healthcare worker” profile.
This incentive has been fixed at a mere Rs 1,000 per month by the Central government. The Haryana government stated that they would pay an additional 50%, bringing the amount to Rs. 1500, only to have that budget rolled back. The incentive is supposed be based on outcomes. With no standardization, the tasks they are asked to perform under the “outcome-based payment” are changed at the whims of department officers.
Lack of formal recognition as public health workers has led to loss of their legitimacy. Public health advocate Anant Bhan said, “ASHAs (and other community health workers) are structurally vulnerable to intimidation because they are perceived to have low status – they are female, at the base of the hierarchical health system, often not rich, not formally employed by the health establishment and are not salaried workers.”
On March 26, Union finance minister Nirmala Sitharaman announced a medical insurance cover of Rs 50 lakh per person for frontline health workers such as sanitation staff, paramedics and nurses, ASHA workers, and doctors. However, an ASHA worker told us a heart-wrenching story that points to the inefficacy of this tokenistic announcement.
In Rohtak, Haryana, an ASHA worker got infected with coronavirus in the line of her work. Her husband who had respiratory problems got infected as well and passed away. However, the cries of her family, as well as her other ASHA colleagues, fell on deaf ears and the health department refused to come to her aid. “Samaaj itna nirdayi kaise ho sakta hai? (How can society be so inhumane)”, she lamented with a cracking voice.
ASHAs are structurally vulnerable to intimidation because they are perceived to have low status – they are female, are not formally employed, are not salaried workers
Lack of formal status and the resulting lack of legitimacy further translates to greater marginalization and harassment. During the early stages of the lockdown, this came to the fore when other that the health department of the government started bossing ASHAs around.
Since she hadn’t left a suicide note, the administration brushed aside the pressure of work as the reason behind her suicide, even as several of her colleagues pointed out to the same. In another incident, an ASHA worker was ostracized from her community after she reported a wedding in the village to the authorities. She was only discharging her duties, but the villagers saw it as a betrayal of their trust.
Over the last eight years, ASHA workers have raised their voices, staged protests, and gone on strikes, only to have been faced with empty promises and FIRs. Their protests are often met with threats of the Essential Services Management Act (ESMA) being invoked. In March 2018, the Maharashtra government’s women and child development department snatched the democratic right to protests from two lakh anganwadi workers.
In Kurukshetra, Haryana, a district collector ordered ASHAs to be stationed at grain mandis for eight hours every day. The police joined in and they were asked to be present at the police station to identify infected residents. Nothing new, indeed: In Muzaffarpur, Bihar, more than 100 children died of Encephalitis in 2017 because ASHA workers supposed to keep tabs on children were asked to conduct election duty.
The government’s lack of empathy and concern has in the past stripped these workers of their basic dignity as well. They had to struggle for two years after the National Rural Health Mission (NRHM) decided to print ASHA on the condom packets distributed by them among people for the sake of family planning. An ASHA worker from Bhiwani, Haryana recalled incidents of eve-teasing and shouts of “Aye ASHA, condom de (give me condoms)” as a result of this campaign.
An ASHA union leader from Haryana told us that most ASHAs are under depression which has gone unnoticed. The 16-state survey of ASHAs conducted by BehanBox where ASHAs cited feelings of being undervalued and alienated amidst long working hours to be the cause of this stress. Their unwavering commitment to their work also leads to domestic discord as well as their alienation in the community.
In Bhiwani, an ASHA worker got called on to submit a report urgently while she was preparing breakfast for her family. Torn after repeated follow-up calls, she left the food preparation midway and went to discharge her duties. When she came back a few hours later, a fight ensued with her husband. Already under immense pressure, she took the drastic step of committing suicide. The government’s lack of empathy and concern has in the past stripped these workers of their basic dignity as well. They had to struggle for two years after the National Rural Health Mission (NRHM) decided to print ASHA on the condom packets distributed by them among people for the sake of family planning. An ASHA worker from Bhiwani, Haryana recalled incidents of eve-teasing and shouts of “Aye ASHA, condom de (give me condoms)” as a result of this campaign.
An ASHA union leader from Haryana told us that most ASHAs are under depression which has gone unnoticed. The 16-state survey of ASHAs conducted by BehanBox where ASHAs cited feelings of being undervalued and alienated amidst long working hours to be the cause of this stress. Their unwavering commitment to their work also leads to domestic discord as well as their alienation in the community.
Since she hadn’t left a suicide note, the administration brushed aside the pressure of work as the reason behind her suicide, even as several of her colleagues pointed out to the same. In another incident, an ASHA worker was ostracized from her community after she reported a wedding in the village to the authorities. She was only discharging her duties, but the villagers saw it as a betrayal of their trust.
Over the last eight years, ASHA workers have raised their voices, staged protests, and gone on strikes, only to have been faced with empty promises and FIRs. Their protests are often met with threats of the Essential Services Management Act (ESMA) being invoked. In March 2018, the Maharashtra government’s women and child development department snatched the democratic right to protests from two lakh anganwadi workers.
When ASHAs demand that gynaecologists and paediatricians be staffed at community health centres, the authorities tell them that this is not for them to raise. Only 2 out of 128 health centres in Haryana have gynaecologists, even as state government guidelines mandate their presence. When they raise the issue of regular pay and status as formal workers, they receive reactions ranging from apathy to ignorance.
A leader from the Hind Mahila Sabha, Uttar Pradesh (UP), told us that the UP chief minister’s office refused to grant them appointments. Some sympathetic bureaucrats agreed to meet them but feigned ignorance, knowing that ASHAs’ demands are legitimate, but they can do anything.
In Bihar, ASHA workers from multiple villages pooled money to be able to send a representative to Patna to participate in the month-long strike in front of the health department and the chief minister’s house. However, they all had to return after a month of dejection.
When we asked an ASHA worker from Bihar whether she would participate in such protests again, she said, she is not interested as nothing came out of it. “I lost my income for a month”, she bemoaned, adding there was lack of any form of attention from media. “Kam se kam akhbaar mein nikalta to lagta koi sun raha hai (at least, if the newspapers had covered it, we would have felt heard)”, she said.
A senior IAS officer, even as agreeing that their demands are legitimate, cited that the major implementation roadblocks include the pressure on the fiscal system to fund the formalization of workers and increased incentives as well as the need for formal recruitment processes to bring ASHAs under the ambit of formalization. She argued, a fixed salary can lead to complacency, whereas an incentive-based system ensures accountability.
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*Second-year students at the Indian Institute of Management, Ahmedabad. Based on interaction with ASHA workers’ union leaders and government officials
A leader from the Hind Mahila Sabha, Uttar Pradesh (UP), told us that the UP chief minister’s office refused to grant them appointments. Some sympathetic bureaucrats agreed to meet them but feigned ignorance, knowing that ASHAs’ demands are legitimate, but they can do anything.
In Bihar, ASHA workers from multiple villages pooled money to be able to send a representative to Patna to participate in the month-long strike in front of the health department and the chief minister’s house. However, they all had to return after a month of dejection.
When we asked an ASHA worker from Bihar whether she would participate in such protests again, she said, she is not interested as nothing came out of it. “I lost my income for a month”, she bemoaned, adding there was lack of any form of attention from media. “Kam se kam akhbaar mein nikalta to lagta koi sun raha hai (at least, if the newspapers had covered it, we would have felt heard)”, she said.
A senior IAS officer, even as agreeing that their demands are legitimate, cited that the major implementation roadblocks include the pressure on the fiscal system to fund the formalization of workers and increased incentives as well as the need for formal recruitment processes to bring ASHAs under the ambit of formalization. She argued, a fixed salary can lead to complacency, whereas an incentive-based system ensures accountability.
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*Second-year students at the Indian Institute of Management, Ahmedabad. Based on interaction with ASHA workers’ union leaders and government officials
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