- Tanmaya Arora
ASHA WORKERS - THE INVISIBLE BACKBONE OF THE INDIAN HEALTHCARE SYSTEM
This article explores the duties of ASHA workers and their contribution to the COVID-19 pandemic. The ASHA workers have been the invisible backbone, holding the Indian healthcare sector together by contributing and volunteering tirelessly to aid those infected by COVID-19. It is vital to talk about and explore their duties and responsibilities as healthcare workers, their status as “informal workers”, their lack of salaries and job security, and the exploitation they have faced during the pandemic.
The Social Development of a nation is directly proportionate to the health of its citizens. While India was making considerable progress in the reduction of indicators such as the Maternal Mortality Ratio (MMR) and Infant Mortality Rate (IMR), the rate of decline was not sufficient to achieve the Millennial Development Goals by 2015. Maternal and natal health indicators in India were nowhere close to displaying the success rate that was needed to achieve global or national targets.
To assist them in achieving these goals and ensuring the last mile of delivery of health services, the Government of India launched the National Rural Health Mission (NRHM) on April 12, 2005. The NRHM is meant to address the state of the existing health system, increase the spending on health and provide a decentralized system of healthcare, that would reach the rural population. One of the main strategies of the NHRM to address the deficiencies in the healthcare system and promote maternal and child health care at household levels, was the creation of the Accredited Social Health Activists, or ASHA workers, in 2006. 
Fourteen years after their inception, the ASHA workers are playing an indispensable role during the global COVID-19 pandemic. Approximately 9,00,000 ASHA workers have been working tirelessly through the pandemic to ensure last-mile delivery of essential medical services such as tracking the status of COVID positive patients, educating families about isolation, and conducting home visits in their assigned areas.
Through the years, ASHA workers have been the most “overworked and underpaid” actors of the Indian healthcare system. In this paper, I will discuss the responsibilities of ASHA workers and the remuneration they receive, the role they are playing in the pandemic, the conditions of work they face, and the need to include them in the formal workforce.
Roles and responsibilities of ASHA workers
The appointment of ASHA workers in every village of the country is a key component of the National Rural Health Mission’s vision to decentralize and strengthen district-level health planning. To be an ASHA worker, a woman must have at least 10 years of formal education, and ideally must be residing in the village and be within the ages of 25 to 45 years. They undergo continuous training to acquire the knowledge and skills needed to satisfactorily perform their duties. 
ASHAs work as health activists to empower women in their villages and communities to make healthy decisions after understanding determinants such as nutrition, sanitation, and hygiene. ASHA workers also counsel women on the preparedness required at the time of giving birth, the importance of a safe delivery, breastfeeding, immunization for the women and their children, the existence and use of various types of contraception, the prevention of common sexually transmitted infections and care of their children. When required, they accompany pregnant women in their villages to health centers for their pre-natal, post-natal, and ante-natal checkups and accompany children in need of treatment or admission to the nearest health care facility. ASHA workers are trained to provide primary medical care for minor illnesses such as diarrhea and fevers and first aid in case of minor injuries. Under the revised National Tuberculosis Control Program, ASHA workers are to be the executors of the Directly Observed Treatment Short-course (DOTS). Lastly, ASHA workers are to maintain an account of healthcare indicators in their areas and inform the ministry officials about the births and deaths in their villages, and report any unusual issues or disease outbreaks in the community. 
Criteria for and Challenges of Renumeration of ASHA workers
Despite these mounts of responsibilities, ASHA workers are seen as healthcare volunteers in their community, as opposed to being looked at as healthcare workers, and thus do not receive any salary or honorarium. They are enumerated on a Performance-Based Payment (PBP) system. The suggested compensation package for ASHAs under the NRHM is based on a list of core activities performed by them in support of various health initiatives. Specifically, for instance, under the compensation scheme suggested in 2012, an ASHA worker gets compensated Rs 350 for performing an institutional delivery under the Janani Suraksha Yojana (JSY) (Rural), Rs 150 and Rs 200 for motivation for tubectomy and vasectomy respectively, Rs 150 for an immunization session, Rs 150 for organisation of Village Health Nutrition Day, Rs 250 for implementation of DOTS and Rs 75 for promotion of household toilet. The compensation of ASHA workers as of 2020 is a monthly honorarium of a meagre Rs 2000 to Rs 4000, which varies in all states across the nation.
An in-depth evaluation of the ASHA program, however, brings to light several challenges that reduce the effectiveness of the PBP system. In most states, the primary challenge is that of a delay in payments of ASHA workers, due to the poor implementation of a cumbersome payment process. Studies have shown that this delay acts as a disincentive for ASHA workers and reduces their motivation to meet their targets. There is a lack of clarity on the remuneration process, and also among ASHAs on how much compensation they are entitled to for the services provided.
There are a large number of other challenges such as a lack of transparency of the incentive payment process, competition with other providers such as Anganwadi workers (AWW) and Auxiliary Nurse Midwives (ANM), who receive a fixed monthly salary payment. There is also an overlapping of responsibilities with AWWs and ANMs and an unclear division of work among them. Finally, there is the problem of the compensation not keeping in pace with the expectations from and workload of ASHA workers. The amount of work that they are expected to complete, seems to be constantly increasing without a similar increase in compensation.
ASHA workers during the COVID- 19 pandemic
While the citizens of the nation protect themselves from a staggering number of coronavirus infections by retreating into their homes, frontline workers all over the country have faced the deadly virus every day since the beginning of the pandemic. As the country applauds doctors, nurses, police personnel, and other formal health workers, the ASHA workers are performing their duties at the frontlines along with them without any recognition. ASHA workers have been playing multiple roles in the face of the pandemic – of health care facilitators, health activists, service providers, and many more. The responsibilities of ASHAs have varied across sectors, ranging from door-to-door surveillance of COVID positive patients, contact tracing, symptom monitoring, accompanying the sick to nearby medical centers, awareness campaigns, and ensuring isolation of patients. ASHA workers have also been made responsible for documenting numbers during the pandemic and are the sole reason we have any vital local data to study the national trends of the virus. For instance, during the mass migration of the informal workforce that took place at the beginning of the COVID-19 lockdown, ASHA workers tracked over 30.43 lakh migrants who returned to Uttar Pradesh and assisted the state government in their contact tracing and community surveillance efforts. They identified 7,965 persons who displayed symptoms and also regularly checked up on their health status.
The work deliverables of the ASHAs have quadrupled during the pandemic without a simultaneous increase in their remuneration because the government considers their work “voluntary and part-time”. On average, a single ASHA worker is accountable for about 1,000 people and thus, they end up working full time to fulfill the demands of their communities. According to a survey conducted on ASHA workers by Oxfam India in four states – Uttar Pradesh, Odisha, Bihar, and Chhattisgarh, 64 percent of the respondents claimed to have received no monetary incentives for the additional COVID-related responsibilities they have been made to undertake, and only 43 percent ASHAs have been receiving their monthly honorariums.
In addition to not being fairly compensated for their work during the pandemic, ASHA workers have been facing a severe lack of personal protective equipment, since they are not in the position of the formal healthcare workers.
They have been classified as “low-risk workers” according to the Ministry of Health and Family Welfare and thus are only required the use of a triple layer mask and gloves while carrying out their duties. Since the ASHA workers, along with other community health workers, are the first line of defense against the virus, this differentiation and discrimination seem unnecessary and untrue.
It is due to these reasons that on August 7 and 8, around 6 lakh ASHA workers took to the streets to stage a two-day protest demanding a minimum wage of Rs 21,000, recognition in the formal workforce, social security benefits covering the workers and their families and personal protective equipment.  The protest was also a show of solidarity for at least 100 workers who died of the coronavirus disease. Instead of being met with reassurances by the government, the ASHA workers faced FIRs for “violating the lockdown guidelines” in states such as Delhi and Maharashtra.
ASHA workers do not form a part of the formal workforce of the country, despite working long hours tirelessly and performing various duties in the health care sector. Due to their nomenclature as “volunteers” they fail to come under the Minimum Wage Act and other Acts that protect formal workers and thus, cannot claim salaries. One cannot ignore the inherent bias when it comes to these women, as their duties take on the label of “familial duty” in a domestic setup and “social activism” when undertaken at a nationwide scale. There is an unequal distribution of care work within families, with the burden falling disproportionately on women and this is subsequently reflected in the undervaluation of such ‘women-centric’ work at the level of the community, the state, and the nation. ASHA workers are neither unskilled nor unorganized labor, they undergo a rigorous selection process, followed by intensive training, and yet they are seen as mere volunteers who are unable to gain any real recognition for their work.
The efforts of ASHA workers over the years have been crucial in building a decentralized system of healthcare and in strengthening the primary health system of the country. Their contributions to an increase in the numbers of institutional deliveries, immunizations, and decline in maternal and infant mortality rates have been incomparable and deserve recognition. The pandemic has shed light on the double burden that these women have been subjected to.
It is essential to bring ASHA workers and other informal health workers under the gambit of a formalized workforce in healthcare provision, and extend to them the benefits and protection that they rightly deserve. An expansion of opportunities due to formalization along with decent wages for these frontline workers could contribute to the revival of the rural economy by putting wages into the hands of many, and could also push the country closer to its health and nutrition goals.
ASHA workers have truly been the invisible backbone of the Indian healthcare system – overworked, underpaid and not recognized for the sacrifices they make in their line of work. Some have been forced to sacrifice their lives during the pandemic due to the lack of protective equipment. While the government exhorted the nation to applaud the formal health workers, such as doctors and nurses, many ASHAs only had one request – “We might not be important, but the work we do is. Can the government acknowledge us too?” 
 Bisht, R., & Menon, S. (2020, May). ASHA Workers Are Indispensable. So Why Are They the Least of Our Concerns? [News]. The Wire. https://thewire.in/rights/asha-workers-coronavirus
 Coronavirus: Around 6 lakh ASHA workers launch protest, demand better pay, health insurance. (2020, August). [Text]. Scroll.In; https://scroll.in. https://scroll.in/latest/969718/coronavirus-around-6-lakh-asha-workers-launch-protest-demand-better-pay-health-insurance
 Guidelines-on-asha.pdf. (n.d.). Retrieved December 6, 2020, from https://nhm.gov.in/images/pdf/communitisation/task-group-reports/guidelines-on-asha.pdf
 GuidelinesonrationaluseofPersonalProtectiveEquipment.pdf. (n.d.). Retrieved December 6, 2020, from https://www.mohfw.gov.in/pdf/GuidelinesonrationaluseofPersonalProtectiveEquipment.pdf
 Hong Wang, Rajni K. Juyal, Sara A. Miner, & Elizabeth Fischer. (2012). Performance-Based Payment System for ASHAs in India: What Does International Experience Tell Us? (p. 36) [Technical Report]. https://www.intrahealth.org/sites/ihweb/files/files/media/performance-based-payment-system-for-ashas-in-india-what-does-international-experience-tell-us/PerformanceBasedPaymentSystemASHAsIndiaReport.pdf
 India coronavirus: The underpaid and unprotected women leading the Covid-19 war. (2020, April 17). BBC News. https://www.bbc.com/news/world-asia-india-52279025
 Koul, S. (2019, September 23). Overworked and underpaid: There’s no hope for ASHA workers [Blog]. Gaon Connection. https://www.gaonconnection.com/read/asha-workers-are-unhappy-because-of-low-salaries-erratic-work-schedule-and-long-working-hours-46300
 Mane, A., & Khandekar, S. (2014). Strengthening Primary Health Care Through Asha Workers: A Novel Approach in India. Primary Health Care: Open Access, 04(01). https://doi.org/10.4172/2167-1079.1000149
 National Health Mission. (n.d.). Retrieved December 6, 2020, from https://main.mohfw.gov.in/sites/default/files/02%20ChapterAN2018-19.pdf
 Nilanjana Bhowmik. (2020, June 1). Millions of women volunteers form India’s frontline COVID response. National Geographic. https://www.nationalgeographic.com/history/2020/06/millions-women-volunteers-form-india-frontline-covid-19-response/
 Nupur Dogra. (2020, August 27). Accredited Social Health Activists struggle for survival. TheLeaflet. https://www.theleaflet.in/accredited-social-health-activists-struggle-for-survival/
 Press Trust of India. (2020, July 1). ASHA Workers Played Critical Role In COVID-19 Management In Uttar Pradesh, Tracked 30.43 Lakh Migrant Returnees | News. NDTV-Dettol Banega Swasth Swachh India. https://swachhindia.ndtv.com/asha-workers-played-critical-role-in-covid-19-management-in-up-tracked-30-43-lakh-migrant-returnees-46495/
 Raina, A. (2020, September 21). ASHA workers are hailed as Covid warriors but only 62% have gloves, 25% have no masks. ThePrint. https://theprint.in/opinion/asha-workers-are-hailed-as-covid-warriors-but-only-62-have-gloves-25-have-no-masks/506623/
 Sinha, D. (2020, September 5). Why society owes Asha workers a debt [News]. Hindustan Times. https://www.hindustantimes.com/analysis/why-society-owes-asha-workers-a-debt/story-sKhgxsrNcH9mShfVhYaFzL.html
Cover Image: Prasant Madugala/EPS
About the author: Tanmaya Arora is a Masters of Public Policy student at the Jindal School of Government and Public Policy.