The women of ASHA: overworked, underpaid and on the edge of breakdown

There’s a saying in the Chhattisgarhi dialect. Sukh mein sab hain, dukh mein Mitanin. Everyone is there in times of joy, but in sorrow, there are only Mitanins. The word translates to ‘friends’. A friendship, between women, one with the promise of compassion. In 2002, Mitanins also came to symbolise care, when the newly-formed State of Chhattisgarh designated women to play the role of community health workers. They were advocates for resource-deficient communities, friendly faces of a distant health system, agents of both change and care work.

Mitanins inspired the ASHA framework three years later. The Accredited Social Health Activist – a saree-clad cadre of almost 10 lakh women today – is a friend. Her care work dictates the reach and success of India’s health schemes. But agents of change tire too. Every ASHA logs in a ‘triple shift’, spread out between the home, community and health centres. Overworked and underpaid, they are caught in a frenzied rhythm: many do not eat well and sleep enough, and are at risk of anaemia, malnutrition and non-communicable diseases, found a new study supported by the Amit Sengupta Fellowship on Human Rights. It documented the limited autonomy the health workers have over their time, money and well-being. 

Experts place the ASHAs’ triple burden along an axis of power inequities – where gender, caste, and informal economy intersect. As women ‘volunteers’, and not designated health care workers, ASHAs experiences cut across “layers of marginalisation”, says Bijoya Roy, a public health researcher at the Centre for Women’s Development Studies. There is an economic, physical and psychological violence embedded in their role, crafted carefully by a system that refuses to assign value to their labour. “ASHAs provide care, but they are not cared for by anyone, not by the system in any way.” It is only during the recent Interim Budget that the Central government announced its decision to provide free health insurance cover for all ASHAs and Anganwadi workers and helpers under the Ayushman Bharat Scheme. In 2018, the Ministry of Health and Family Welfare approved an ASHA benefit package, providing coverage for accidents, deaths and disability.

A day at work

The survey, conducted during COVID-19, traced the lives of 40 ASHAs in Phanda block in Bhopal. Day starts at dawn for many. They cook, fetch water, complete other chores, and soon begin visiting houses in the community. Meals are erratic and irregular: almost 30% of ASHAs said they do not have time to eat in the morning; some carry food for lunch, while others say they were forced to purchase from the market . About 13% of ASHAs said they do not eat anything the whole day. Back home, the women said they were the last to eat their meals in the family.

Almost half of the ASHAs also do not get enough sleep or rest. “The ASHA has a triple burden that all women workers carry,” explained Vandana Prasad, a public health professional associated with Public Health Resource Network. “She is doing housework, childcare, and looking after all homes and families for the health system – that too at very poor remuneration.” In Phanda, more than half were married at the age of 18-20 years, and about 50% of the ASHAs had their first child before 25. 

“An ASHA is the only interface there is between the health system and the community. ”Vandana Prasad

Outside of homes, the duties under their umbrella of work have expanded too: it started with maternal and child health, and now includes vaccination follow-ups, data logging, learning palliative care, reporting domestic violence cases, providing mental health support, and more. “In the name of shifting work, we are adding to the burden on volunteers who are underpaid and overworked,” remarks Dr. Roy.

Extreme weather conditions add a degree of precarity. ASHAs are on their feet or use a cycle during peak humidity and heat. Reports suggest the occupational hazards of working through heat waves or erratic weather will imperil the informal labour force. Extreme heat also creates a double burden’ for women, according to an Adrienne Arsht-Rockefeller Foundation Resilience Center report. They are more vulnerable to getting sick from heat, while being responsible for providing paid and unpaid care work. Deteriorating environmental conditions alter their site of work, but “there is little discussion around changing the timing of work” or offering them protective shields, Dr. Roy said. Some States offer raincoats, umbrellas and cycles to ASHAs, but policy needs to become more conscious of their needs, she adds.

ASHAs’ vulnerability to heat stress doesn’t technically qualify as an ‘occupational hazard’ – an ASHA is a volunteer, not a ‘worker’ in the eyes of the system. “The term ‘occupational hazard’ itself essentially implies that somebody is in an occupation…but an ASHA is denied that. Everything she’s doing is at her own risk,” explains Dr. Prasad.

“There is no balance – between their workload, wages, and the rest and recuperation they need as individuals.”Bijoya Roy

Their eating habits, irregular times and paucity of nutritious food make them vulnerable to malnutrition, anaemia and non-communicable diseases. Almost half of the ASHAs surveyed in Phanda fall in the obese or overweight category; less than 3% are underweight. The demands placed on their time and body also increased the risk of non-communicable diseases, the report found. 

An ASHA’s health is not an individual burden: only if she is fit — emotionally and physically — can she work for the benefit of women, children and society. A recent PLOS Global Public Health study adds weight to this link: the likelihood that a woman accesses maternal services, and has a safer, institution-based delivery goes up by 1.6 times if they were connected with ASHAs. A “continual, systematic investment to strengthen the ASHA program” is inextricably linked to advancing India’s child and maternal health outcomes, the researchers argued.

Monetary barriers

As volunteers, ASHAs receive an honorarium and performance-based incentives. Among Madhya Pradesh’s ASHAs, family monthly incomes varied between ₹5,000 to ₹15,000. Moreover, ASHAs relied heavily on health department’s incentives , and very few earned additional income as domestic workers or through local businesses.

It becomes a form of “economic violence”, notes Dr. Roy, when their wages are delayed and fixed honorariums are received months later. ASHAs incur out-of-pocket expenditures for the logistical costs of their job  – on photocopies, travel, mobile data recharge. ASHAs in Bhopal spent up to 63% of their income on logistical costs, which the department failed to reimburse.

. As honorary workers, however, their health is still not covered under the Central Government Health Scheme (CGHS) or similar programmes. ASHAs as health workers do have greater access to PHCs.

Exclusion from the CHGS itself “shows how much the health system cares for the people who service others,” says Dr. Roy. ,

Many faces of violence

Gender and caste hierarchies within the health system further shape ASHAs’ well-being. Reports of ASHAs facing abuse, harassment and assault receive scarce coverage; some were highlighted during the COVID-19 pandemic. As the physical embodiment of a public health system, “when things go bad, the system disowns her and the community attacks her”, Dr. Prasad notes. Without redressal systems or the space to voice her concerns, she “has nowhere to go”. 

Historically, ASHAs and other female health workers come from marginalised communities. They work with the Panchayati Raj Institutions (PRIs) and medical systems – entities where the social composition is traditionally of men from privileged communities. Working within this health system is a “source of stress”, notes Dr. Prasad. “ASHAs have always been the lowest rung in the health system…the least powerful.”

“ASHAs have access to the health professionals and health system in a way that the community doesn’t have.”Vandana Prasad

A conflict operates in their role as ASHAs. There is a greater sense of status and belonging in the community. As women, it also gives them the freedom to occupy public spaces and move outside domestic spaces. “They gain power in the community, but in the health system, they’re powerless,” says Dr. Prasad.

Looking after India’s ASHAs

The National Health Systems Resource in 2011 published a report documenting ASHAs’ duties, hierarchy and reporting mechanism. The document made no mention of working conditions and the challenges they face.

Many ASHAs join in anticipation of becoming permanent workers, attaching themselves to a system in the hope that it may eventually offer social security. Resistance without resolution, for months and years on end, feeds into their powerlessness and intensifies emotional violence. One ASHA said they are expected to be chained to their phone; many ASHAs work under fear of being fired if they deny care services.

The expectation has eluded them thus far. Across the country, millions of women health workers — ASHAs, ANMs and Anganwadis — are mobilising. Roads in Maharashtra, Andhra Pradesh, Karnataka are covered in hues of pink and red. They demand a fixed honorarium; stipulated working hours; access to maternity leaves and pension benefits. All institutional rights that come with being a ‘government employee’.

“The most important thing to say about [an ASHA] is that she’s not being given the status of a health care worker – and everything else leads into or derives from that,” Dr. Prasad notes. Care work empowered them, but it also immiserated them physically and emotionally.

Dr. Prasad argues that India should “bite the bullet.” “If all ASHAs decide to go on strike and refuse to work, the health system will fairly collapse.”

Without any policy change, the system will continue to frame ASHAs as ‘volunteers’, neglecting their rights, knowledge and welfare. To the community, the saree-clad women long ago transcended the ‘volunteer’ label. One woman in Phanda sees them as a friend — as ASHAs work, “everyone becomes united in happiness and sorrow”.

(This story is part of the Amit Sengupta Health Rights Fellowship. The survey was conducted by Shilpa Jain in 2021, during the COVID-19 lockdown.)

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