The one million Accredited Social Health Activists (ASHAs) in India have played a pivotal role in improving healthcare access by increasing institutional deliveries and vaccination rates, and by bringing essential services to remote and marginalized communities. Their efforts have been instrumental in advancing the availability, accessibility, acceptability, and quality of healthcare, as outlined in General Comment 14 of the United Nations Committee on Economic, Social, and Cultural Rights. However, ASHAs remain on the periphery of the formal health workforce. Their classification as “volunteers” has led to precarious working conditions, including inadequate pay, undefined working hours, and a lack of employment rights, social security, and institutional support. This article examines the significant challenges ASHA workers face in claiming their basic rights and argues that extending labour protections to them is essential for achieving universal health coverage.
Background
The concept of Community Health Workers (CHWs) has long been recognized as a cornerstone of public health initiatives. CHWs are frontline health workers who act as a bridge between healthcare providers and the communities they serve. In India, the idea of CHWs gained prominence as early as 1940, when the Sokhey Committee recommended their integration into the healthcare system to address the gap between providers and local communities. Despite this early recognition, the formal implementation of a national CHW program did not occur until 1977.
That year marked a significant milestone with the introduction of the Swasthya Raksha Scheme, which aimed to engage communities and promote health and well-being by deploying approximately 400,000 male workers across the country. However, the program soon began to decline, partly due to the replacement of male workers with women. Although the program continued until 1985, and in some states until the 1990s, it gradually became dysfunctional.
The 1978 Declaration of Alma-Ata further emphasized the importance of community participation in healthcare, advocating for the involvement of individuals and communities in the planning, implementation, and evaluation of healthcare services. Against this backdrop, in 2005, as part of India’s National Rural Health Mission (NRHM), a group of trained female health activists known as Accredited Social Health Activists (ASHAs) was introduced. ASHA, meaning “hope,” was created to serve as a “bridge” between rural populations and healthcare services, playing a central role in achieving national health and population policy goals. With the launch of the National Urban Health Mission, ASHAs can now also be found in urban areas, primarily serving vulnerable communities and people living in informal settlements.
ASHA Workers and Their Role
Established in 2005 as key figures in India’s National Rural Health Mission, ASHAs are female volunteers selected from villages across the country to act as “links” between marginalized communities and the formal health system. They also provide basic preventive and curative services, as well as public health information. ASHA workers are typically preferred to be between 25 and 45 years old, with a minimum of eight years of formal education and demonstrable leadership qualities; however, some flexibility is allowed in certain cases during the selection process.
Role of ASHAs
ASHAs primarily assume three key roles within the community: link workers, service extension workers, and health activists. Their responsibilities include but are not limited to, providing primary medical care with their kits, educating the community on disease control, offering antenatal, natal, and postnatal services to women, providing counselling on family planning and safe abortion, promoting behavioural changes in breastfeeding and birth spacing, conducting health surveys, mobilizing the community for local health planning, and increasing the utilization of existing health services.
The involvement of ASHAs in the healthcare system has led to significant improvements in maternal health, with key health indicators such as the maternal mortality ratio (MMR), infant mortality rate (IMR), and total fertility rate showing a decline. India’s MMR decreased from 384 in 2000 to 103 in 2020, while the IMR dropped from 37 per 1,000 live births in 2015 to 30 per 1,000 live births in 2019 at the national level. The utilization rate of ASHA services by pregnant women was found to be 89.7% (Bhattacharya, 2017).
Factors Contributing to Marginalization
Economic
Since ASHA workers are voluntary, the central government under the National Rural Health Mission (NRHM) pays a fixed honorarium of only ₹2,000 per month. In addition to this, ASHAs are expected to receive performance-based incentives for their healthcare delivery services. However, these incentives are often inadequate and do not fully cover the scope of ASHA work. Currently, there is no standard procedure for revising the incentives or honorariums (Abdel-All M., 2019). Furthermore, a bureaucratic labyrinth impedes timely compensation. Delays in salary payments not only highlight the financial vulnerability of ASHA workers but also raise significant human rights concerns. The failure to provide timely and fair remuneration violates their right to just and favourable conditions of work, as outlined in various international and Indian human rights instruments, including the Universal Declaration of Human Rights, the International Covenant on Economic, Social, and Cultural Rights, and Part III (Fundamental Rights) of the Indian Constitution.
COVID-19 has only worsened the economic hardships faced by ASHA workers. On average, they earn around ₹3,000 in incentives for various task-based activities. However, during the pandemic, many of these tasks—such as family planning, antenatal and postnatal care, home-based follow-up of newborns, immunization, adolescent health, and cancer surveys—were suspended. The central government announced an additional incentive of ₹1,000 per month for COVID-19 duties, but this fell far short of compensating for the loss of regular earnings. The situation was further aggravated by a lack of access to personal protective equipment (PPE), protective gloves, and medical kits, adding to the heightened stress.
Even when gloves and protective kits were provided, logistical challenges—such as having to collect the protective gear from distant healthcare facilities and covering transportation costs out of pocket—demotivated ASHAs from retrieving them. A survey conducted by Oxfam in the states of Uttar Pradesh, Bihar, Odisha, and Chhattisgarh found that at least 25% of ASHA workers did not receive basic necessities such as sanitisers, and only 23% received PPE body suits. Additionally, two-thirds of ASHA workers did not receive the promised COVID bonus, and less than 50% received their monthly honorariums on time.
Moreover, ASHAs are also deprived of social security benefits. The absence of social safety nets and inadequate support mechanisms exacerbates the financial precarity of ASHA workers. Without access to affordable healthcare, insurance, or pension schemes, they remain highly vulnerable to economic shocks, perpetuating cycles of poverty and deprivation. Additionally, ASHAs face challenges such as a lack of support from primary healthcare (PHC) staff, insufficient training, unclear reimbursement policies, and poor guidance on how to collaborate with Auxiliary Nurse Midwives (ANMs) and Anganwadi workers (Gasavi et al., 2009).
Individual Level Challenges
In addition to their exclusion from the formal regulation of employment conditions, ASHAs face further labour-related discrimination due to their gender. Predominantly women, ASHAs experience various overlapping forms of discrimination arising from their gender, lower socioeconomic status, rural location, lower levels of education, and low standing within the health workforce (Ved R., 2019). Most ASHAs are not the primary earners in their families; however, due to their accountability to their families regarding daily activities, they often feel pressured to discontinue their work, as it is not considered domestic labour. Families act as “uncounted” stakeholders in ASHAs’ understanding of work, which obstructs their ability to assert their right to work in environments free from undue influence and coercion.
The significant burden experienced by ASHA workers is a major concern. Although maternal and child health services are their primary responsibilities, they often find themselves conducting household surveys, epidemic surveys, or election duties. The imposition of numerous tasks not only stretches their time and resources but also diverts their focus from essential maternal and child health services. The COVID-19 pandemic has exacerbated this strain. Most regular tasks, aside from caring for pregnant women, were put on hold during the lockdown; however, the average number of working hours still increased. This was due to new responsibilities assigned to ASHAs, including surveying households to collect information on travel histories and health profiles of household members, providing guidance and monitoring quarantined patients, and encouraging people to practice precautions such as social distancing, handwashing, and wearing masks. This overwhelming burden negatively impacts their well-being and personal satisfaction.
Social Factors
The social hardships endured by ASHA workers are deeply intertwined with the prevailing sociocultural norms and gender dynamics within their communities. Traditional gender roles restrict their ability to fulfil their professional responsibilities. As primarily female workers, ASHAs face a dual burden: societal expectations to uphold traditional gender roles within the household and the professional obligations imposed by their roles in healthcare delivery. Failing to meet the expectations of being a “good” daughter-in-law or “good” wife can lead to abandonment by their husbands or elders.
Additionally, while performing their duties, ASHAs often encounter community misconduct, and sometimes even harassment. During the pandemic, ASHAs faced increased stigma; they were perceived as potential spreaders of the virus upon returning from work. A survey conducted by Oxfam revealed that 33% of ASHA workers experienced discrimination and violence while carrying out their duties during this time.
Policy Recommendations
ASHAs’ precarious and unsalaried position in India’s health system hierarchy has led them to unionize and advocate for their recognition as regular employees with more secure working conditions (Bhatia, 2014; Ved et al., 2019). Currently, several state-level ASHA protests have resulted in increases in base salaries and garnered greater attention from mainstream media (Ghosh, 2021). While state-specific gains are important, the uneven governance and social protection across states contribute to deepening spatial inequities among the poor. Addressing ASHA concerns solely at the state level will likely exacerbate this tendency.
At the central level, a legal framework addressing the myriad challenges faced by ASHA workers was proposed in the ASHA Workers (Regularization of Service and Other Benefits) Bill, 2020. This bill seeks to regularize the services of ASHA workers and confer upon them the status of permanent government employees, along with related provisions. However, despite its potential to address key issues, the bill has not yet been passed.
In crafting a legal and policy framework for ASHA workers, it is essential to prioritize their rights, protections, and well-being while ensuring the effectiveness and sustainability of community health initiatives. The following are key elements that must be included to effectively promote the participation of ASHAs in community-level healthcare:
Employment Rights: The current system of remuneration makes it difficult for ASHAs to meet their families’ needs and the community’s expectations. If ASHAs are to remain a key component in achieving universal health coverage in India, adequate, transparent, and equitable institutional mechanisms must be established for timely remuneration and incentives as soon as possible. ASHAs should be compensated according to the Minimum Wages Act of 1948. This act safeguards the interests of workers who are vulnerable to exploitation due to illiteracy and lack of bargaining power, and it requires employers to pay the minimum wages fixed under the statute for the work performed during a given period. Furthermore, payment and reimbursement procedures need to be simplified. It is high time to grant ASHAs the recognition they deserve by extending full rights and entitlements in accordance with labour laws, including leave, provident funds, medical and educational allowances, safe working conditions, standard working hours, and protection against exploitation.
Adequate Training and Capacity Building: The ASHA program under the NRHM is considered to have the potential to generate community participation through its implementation (Joshi and George, 2012); however, this can only be achieved with adequate orientation training. An integrated training program must be designed to promote greater cooperation between ASHAs and the community. Additionally, there is an urgent need to develop a capacity-building strategy that focuses on utilizing technology and implementing supervision initiatives.
Complaint Mechanisms and Grievance Redressal: There is a need to develop support systems for grievance redressal, protection against sexual harassment, physical and mental well-being, and stigma prevention, with clear accountability. Local committees, as mandated by the Protection of Women at Workplace (Prevention, Prohibition, and Redressal) Act of 2013 (a result of the landmark Vishakha judgment of 1997), must be established to adjudicate complaints of sexual harassment in informal workplaces.
Integration with Other Stakeholders: Integrating ASHA workers into the broader health system by facilitating coordination, collaboration, and communication with other healthcare providers and grassroots-level functionaries, such as Anganwadi workers and Auxiliary Nurses and Midwives (ANMs), is crucial for ensuring seamless delivery of healthcare services and continuity of care. Activity mapping should also be conducted to avoid the duplication of tasks and wastage of resources.
Conclusion
The lack of integration into the formal, salaried cadre of healthcare personnel leads to discontent and undermines their right to a livelihood. Incentive-based payments do not align with the wages stipulated under various acts, such as the Minimum Wages Act and the Equal Remuneration Act, and fail to provide financial security. Untimely remuneration, uncertain working hours, power imbalances, and a lack of community cooperation have amplified their vulnerability, hindering their ability to effectively exercise their rights. Addressing these complex issues requires collective action to embed labour rights within the existing policy framework. It is imperative to recognize ASHA workers as equal partners in the healthcare system to strengthen the foundation of healthcare infrastructure.
References
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Bhattacharya, H., Luwang, N., Sarkar, M., Chakraborty, T., & Baidya, S. (2017). Utilization of ASHA services by the pregnant women of rural Tripura, India. International Journal of Research in Medical Sciences, 3(9), 2223–2227. https://doi.org/10.18203/2320-6012.ijrms20150606
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Joshi, S R and George, M (2012): “Health Care through community participation”, Economic & Political Weekly, Vol. XLVII, No.10, pp 70-76.
Ved R., Scott K., Gupta G. et al. 2019. “How are gender inequalities facing India’s one million ASHAs being addressed? Policy origins and adaptations for the world’s largest all-female community health worker programme,” Human Resources for Health. 2019;17(3):3.[Google Scholar]
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https://nhm.gov.in/index1.php?lang=1&level=1&sublinkid=150&lid=226
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