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

ASHAs engage in the double burden of domestic chores while running around the community as health workers, resulting in improper nutrition, inadequate sleep and deprioritising their own health. They are at risk of anaemia, malnutrition and non-communicable diseases

ASHA workers protesting in Bengaluru on February 13, 2024. Image for representational purpose only. File | Photo Credit: Murali Kumar K.

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 Dr. Amit Sengupta Fellowship on Health 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 dismisses their knowledge, and 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 due to paucity of time. 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– a gendered food allocation practice that reflects the larger trend in India. 

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. 

Given that it is entirely a woman cadre, Dr. Prasad notes that “gender undoubtedly plays a huge role”.

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. Experts pointed out the emotional costs designed in an ASHA’s role. They are intimately connected with women and children; and carry the community’s well-being on their shouldersburnout and stress are stitched into their sarees, as every scheme, programme, and target depends on their performance.

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. Dr. Roy notes growing heat stress is posing a challenge for ASHAs. 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. A similar precarity applies to those who operate in the informal workforce, such as gig workers, but the public sector nature of work separates ASHAs. “They’re not going to homes to do private work similar to a domestic worker…They’re operating in a government space,” Dr. Prasad explains. 

Despite this, “There has not been any concerted effort to monitor their health, physical or emotional” Dr. Prasad notes. Among other concerns, the ASHAs in Phanda expressed the need for health and life insurance schemes. 

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. The report also found ASHAs’ wages are the primary source of income for their families. Moreover, ASHAs relied heavily on health department’s incentives received from the health department, 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 routinely 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. ASHAs also said they sometimes purchased medicines for patients and paid the fare for escorting them to hospitals. This further reduces the disposable income for ASHAs’ own healthcare needs and depletes their ability to care for themselves, experts suggest.

The casualisation of their work erodes the possibility of social security measures, such as health insurance. 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. The Union Government’s Interim Budget extended this cover to all ASHAs and Anganwadi workers. Studies, at the same time, suggest significant coverage gaps within the PMJAY, noting its “poor grievance reprisal, poor claim processing and settlement, denial of reimbursement of health packages”.

Exclusion from the CHGS itself “shows how much the health system cares for the people who service others,” says Dr. Roy. “One may not have access to resources [such as clean water or clean air], but when you are denied the basics – fair and timely wages, social security, dignity – it does little to protect your health.”

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. Among the ASHAs surveyed in Phanda, a sizable number also belonged to the Scheduled Castes and Scheduled Tribes. 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.”

In Bhopal, some ASHAs were unschooled, less than 3% had a postgraduate degree, and the highest level of education for most was until the 10th grade. This limits the professional paths to skill, which further disempowers them. Take the growing reliance on app-based work. “If there is no training in that area, the community health workers who are coming from marginalised are further marginalised,” Dr. Roy notes, adding that it gives shape to a “double edged-marginalisation.”  

Education is a weapon for an ASHA, experts note. It not only allows her to be more attentive, aware and alert in her role, but elevates her status in the eyes of the community too. The women looked up to ASHAs for support, guidance and information. “Whenever she calls for a meeting in the village, we all come and listen to all her talks,” one woman in Phanda said.

However, within the medical field, community-based knowledge is traditionally dismissed. Dr. Roy notes that while they are seen as warriors, their knowledge systems go unacknowledged.

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 build identities, 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 titled “Evaluation of ASHA Program”, a framework documenting ASHAs’ duties, hierarchy and reporting mechanism. The document made no mention of working conditions and the challenges they face. “’Care’ is not a word which is talked about in policy documents,” says Dr. Roy, despite their jobs packaging both social and healthcare.

Many ASHAs the female cadre join in anticipation of becoming permanent workers, attaching themselves to a system in the hope that it may eventually offer social security. Theirs is a fight against economic and social precarity. 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. Many feel satisfied with their job and are willing to learn, but a sense of “bitterness” lingers, she adds. Care work empowered them, but it also immiserated them physically and emotionally.

Dr. Prasad argues that India should “bite the bullet.”: make them into full-fledged workers, pay them decently and look after them “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, she says “everyone becomes united in happiness and sorrow”.

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