Accredited Social Health Activists or ASHA workers in Bihar went on an indefinite strike from December 1 with a 12-point charter of demands. Bihar has 93,687 ASHA workers – the second highest contingent of the one million ASHA workers in India. They are the key link between the healthcare system and rural populations and have to perform many essential tasks. The strike call was given by the Joint Struggle Forum – the ASHA Sanyukta Sangharsh Manch – comprising of three major ASHA unions in the state.

The scenes from the Bihar ASHA strike are remarkable and inspiring. Thousands of women come to public health centres for sit-ins through the day and night, with local volunteers arranging food and blankets for them. Striking ASHAs blockaded district level hospitals and Civil Surgeon offices. On December 13 and 14, they laid siege to the Bihar Chief Minister’s office, staying there day and night, pointing out that the state has not implemented its own agreement of June 2015 with ASHA unions. The state government had agreed to form a committee to recommend better pay, consider giving them the status of government employees and prohibit and punish misbehaviour by doctors and other medical staff among other things.

With public health services almost completely absent at the grassroots, ASHAs constitute the backbone of India’s rural as well as urban health systems for low-income and the most poor and deprived communities. Yet they are overworked, underpaid and not even recognised as government employees and skilled workers. Instead they are called “voluntary activists” who are paid a token incentive instead of a salary, pension, and other benefits.

The ASHA unions in Bihar are demanding government employee status and a minimum wage – which the government calls an honorarium – of Rs 18,000. Other demands include 50% reservation for ASHAs in state nursing schools with appropriate relaxation of age criteria for admission, appointments for qualified ASHAs as Auxiliary Nurse Midwives, appointments for ASHA facilitators as Block Community Coordinators and social security benefits including ESI and Provident Fund. They also want recommendations made by the high-level committee on the status of women in 2015 regarding regularising work conditions and monthly remunerations to be implemented.

Only hope for rural healthcare

ASHAs are workers in the National Rural Health Mission, a flagship Government scheme. Jayati Ghosh, in her book Never Done and Poorly Paid: Women’s Work in Globalising India, noted that this programme and the Integrated Child Development Scheme that employs the anganwadi workers are “designed and launched by explicitly relying on the unpaid labour of women.” She says the programmes work by “trading on the time-worn stereotype of caring women who serve their families and communities selflessly without any thought of return”.

An ASHA is a local woman who acts as a link between her rural community and the public health system. ASHAs are women who have completed eight years of school, and one ASHA serves one village or a population of 1,000. Each ASHA gets a mere 23 days of training.

The National Rural Health Mission statement calls the ASHA “a health activist in the community who will create awareness on health and its social determinants and mobilise the community towards local health planning and increased utilisation and accountability of health services. She would be a promoter of good health practices. She will also provide a minimum package of curative care as appropriate and feasible for that level and make timely referrals.”

ASHAs are also responsible for:

  • Creating awareness about nutrition, sanitation, hygiene and toilet use, healthy living and working conditions, the existing health services and the need for timely utilisation of health and family services
  • Counselling women on birth preparedness, safe delivery, breastfeeding and complementary feeding, immunisation, contraception, preventing common infections and the care of young children
  • Facilitating access to government health services including immunisation, antenatal and postnatal check-ups, Integrated Child Development Scheme and sanitation
  • Escorting pregnant women as well as sick children to the nearest health facility for treatment or admission
  • Providing primary medical care for diarrhoea, fevers, first aid, as well as TB short course treatment
  • Acting as depot holder for basic health provisions such as oral rehydration solution, iron and folic acid tablets, chloroquine, disposable delivery kits, oral contraceptive pills and condoms
  • Informing health authorities about births, deaths, and any unusual health problems or diseases in the community
  • Promoting toilet construction
  • Working with gram panchayat to develop a comprehensive village health plan

This is a huge amount of work and most of it is skilled work requiring basic medical knowledge, ability to explain health issues to local people, organise campaigns, and diagnostic skill to distinguish between unusual health problems and ordinary fevers and diarrhoea. The nature of the work is such that there are no regular hours and the ASHAs are expected to be on call 24/7. ASHAs are expected to arrange and pay for their own transport to the health centres and hospitals. A recent survey of ASHA workers in Delhi found that they may spend up to 12 hours a day on the job, including transport time; in rural areas, transport may take even longer.

ASHA workers surrounding the Bihar Chief Minister's office. (Photo: Ranvijay of AICCTU, Bihar)
ASHA workers surrounding the Bihar Chief Minister's office. (Photo: Ranvijay of AICCTU, Bihar)

To get a sense of just how important the work of the ASHAs is, we can cast our eye on the crisis of healthcare for women and children in India.

In 2015, India had 40% of undernourished children of the world. India has some of the worst rates of stunting and maternal and infant mortality in the world. The National Health Profile 2018, an annual report released recently by the Central Bureau of Health Intelligence, found that the Government of India spends just 1.3% of GDP for public healthcare – much less than the global average of 6%. The per capita public expenditure by the government on health stands at Rs 1,112, which amounts to a pitiful Rs 3 per day. India spends less on healthcare than Nepal, Maldives, Sri Lanka and Bhutan.

According to the report, one allopathic government doctor in India, on an average, attends to a population of 11,082, which is 10 times more than the WHO recommended a doctor-population ratio of 1:1,000. The situation is worst in Bihar where one doctor serves a population of 28,391 people.

However, the report found that in spite of the government’s low priority to healthcare, there has been “noteworthy progress in health indicators such as the infant mortality rate and maternal mortality rate in the country”. There was a 11-point decrease in MMR between 2010-’12 and 2011-’13.

Clearly, it is the ASHAs, along with the Auxiliary Nurse Midwives and anganwadi workers, who deserve the credit for this achievement. They provide direct prenatal and postnatal care to women and newborns, facilitate institutional deliveries, treat diarrhoea – the number one killer of infants in India, and advise women on nutrition and breastfeeding.

So much work and no salary

The work of ASHAs is disguised as voluntary in order to justify the complete absence of any salary. The NRHM says that the ASHA is an “honorary volunteer and would not receive any salary or honorarium” and that her “work would be so tailored that it does not interfere with her normal livelihood”. So the government, while using the ASHAs as virtually the only available village-level healthcare in rural areas, is claiming this work is just voluntary service and denying it is a livelihood that deserves to be paid.

ASHAs get small incentive payments for every task they can prove they have done, and some state governments have also fixed small monthly payment amounts. But the pay never amounts even to minimum wage for unskilled work and does not come close to the salary and benefits of a government employee.

On 11 September, Prime Minister Narendra Modi announced a hike in the remuneration of Anganwadi and ASHA workers by over 50%. If and when this announcement takes effect, the fact will still remain that these frontline health workers will not get a government salary along with pensions and other benefits.

It is high time we in India learn to acknowledge, appreciate and remunerate the labour of women who are the lifeline of rural healthcare in India.

The writer is Secretary of the All India Progressive Women’s Association.