Report of Survey Conducted Amongst ASHA Workers in Delhi
ASHA (Accredited Social Health Activists) workers are part of the National Rural Health Mission (NRHM) launched in 2005 to provide rural areas access to better healthcare facilities. ASHA workers form the backbone of this scheme. The scheme was initially designed to make sure that there is ‘doorstep delivery’ of health services to rural communities, and ASHA workers became the veritable foot soldiers of this scheme. The burden of reaching the homes of people in rural areas fell on the shoulders of ASHA workers. When the scheme was extended to urban areas, we now have more than 10 lakh women who are working as ASHA workers across the whole country.
Overworked, Underpaid, Unrecognised
As per the NRHM, ASHA workers are supposed to perform a mindboggling number of tasks which includes creating awareness around nutrition and sanitation, counselling women about safe delivery, breast feeding, contraception and prevention of common infections in young mothers and children. They are also expected to facilitate post and pre-natal check-ups and immunization as well as arrange for escort for women and the elderly in need of help to the nearest health centre. On top of this, they are expected to provide first-aid and medical care for diseases such as TB, and diarrhoea. They are also supposed to inform health authorities about the outbreak of disease in a locality or village, and work with panchayats to ensure that health care is provided to all. Women with a minimum qualification of passing their 8th standard are expected to do this after just twenty-three days of training.
Despite being expected to perform the huge number of tasks listed above, ASHA workers continue to be called ‘volunteers’ and thus do not receive a salary. It is quite unbelievable that women are expected to perform such a huge number of specialised tasks without any fixed salary and job security. In nearly all states of India, ASHA workers are paid a paltry sum of Rs. 3000 as monthly honorarium. Because of the nature of the work they do, ASHA workers have to be ‘on call’ 24x7 since there is no fixed time for when someone falls ill or a woman has to give birth. In fact, the ASHA worker is termed as a volunteer because her work is seen as a supplement to the work she does at home. Also, by terming them as volunteers, governments have washed their hands off the responsibility to pay ASHA workers the legally mandated minimum wages. As a result, we have more than 10 lakh women employed as ASHA workers throughout the country who work on an average 10-14 hours every day throughout the year without any leave and are paid only Rs. 3000 per month. To top this exploitative nature of the work done by ASHA workers, very few of them across the country get this paltry sum, termed as honorarium, on time. There are reports from various states which show that payments to ASHA workers are often delayed by at least 2 months.
Since ASHA workers are not termed as workers, they automatically become ineligible to avail many social welfare schemes of the government. Even though in 2018 it was announced that they will be eligible for schemes such as the Pradhan Mantri Jeevan Jyoti Beema Yojana, the free cover under these schemes is only for a year, after which they would have to pay a premium. Apart from this, they are ineligible for any other scheme such as ESI and PF which provides security to workers. So the government, while using ASHA workers for several jobs, claims that the work they do for 12-14 hours a day is just voluntary, and just an addition to household work in the family. In other words, we have a highly exploitative system in place wherein the work women do as ASHA workers for nearly the entire day time is not recognised as a legitimate source of livelihood.
Bearing the Burden of an Underfunded Healthcare System
Despite the Modi government’s hollow claims of ‘Acche Din’ and ‘New India’, the fact remains that large swathes of India’s population do not have access to quality and affordable healthcare. The scenario is graver when it comes to healthcare of women and children.
The National Health Profile 2018, an annual report released recently by the Central Bureau of Health Intelligence (CBHI), found that the Government of India spends just 1.3 per cent of its GDP for public healthcare, way less than the global average of 6 per cent. 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 per capita on healthcare than Nepal, Maldives, Sri Lanka and Bhutan.
In 2015, India accounted for as much as 40 per cent of the world’s undernourished children. India has some of the worst rates of stunting and maternal and infant mortality in the world. 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 doctor-population ratio of 1:1,000. The situation is worst in Bihar where one doctor serves a population of 28,391 people. Uttar Pradesh similarly performs very poorly with 19,962 patients per doctor, and is followed by Jharkhand (18,518), Madhya Pradesh (16,996), Chhattisgarh (15,916) and Karnataka (13,556).
But the same report also mentions that India has improved the infant mortality rate and maternal mortality rate (MMR). It is obvious that despite a severely underfunded public health system, the most important reason for the improvement in the MMR is the backbreaking job done by ASHA workers. JP Nadda, who was the then Health Minister and is now the President of the BJP, trumpeted the decrease in the MMR as an ‘achievement’ of the Modi government. He however did not say a single word to acknowledge the crucial role played by the ASHA workers in achieving this. Clearly, it is the ASHA workers (along with the Auxiliary Nurse Midwives or ANMs and Anganwadi workers) – the only ones providing any direct pre- and post-natal care to women and new-borns, facilitating institutional deliveries, treating diarrhoea which is the biggest killer of infants in India and advising on nutrition and breastfeeding – who deserve the credit for this achievement.
When it is convenient for the government, it will claim credit for the work done by the ASHA workers. However, till now not a single demand of ASHA workers across the country (such as giving them the status of government employees and providing them with job security) has been accepted by the government. The work done by ASHA workers, which ensures that lakhs of young mothers give birth safely and young children do not suffer because of infections, remains till date unrecognised and severely underpaid. ASHA workers remain perennially overworked as the work they have to do is only increasing day by day.
Covid Pandemic Exposes Exploitative Nature of Work of ASHA workers
When the Covid pandemic hit India in early 2020 we could not have been more ill prepared. Even though the first case was detected in the country in January 2020 itself, Modi held a huge gathering to welcome the then US President Donald Trump in Ahmedabad. When the lockdown was announced in March, the healthcare system simply did not have enough preparedness to deal with the pandemic. Unsurprisingly ASHA workers were given a large number of responsibilities in addition to the already mindboggling number of things that they were expected to do in the normal course of their work. Covid necessitates intensive ground-level monitoring, and since ASHA workers are supposed to provide ‘last mile connectivity’ in the public health system, their workload increased significantly.
Throughout the pandemic, ASHA workers have been working as frontline workers against the coronavirus outbreak – performing important tasks such as disease surveillance, reaching out to infected patients with medicine, conducting daily temperature checks in neighbourhoods, monitoring home quarantine and encouraging people to get vaccinated against the virus. They have been made to do most of the grunt work in the public health system during the pandemic, with little or no pay and zero recognition of the risks they have undertaken in the process. They have put their own lives in danger while carrying out their responsibilities. An overwhelming number of ASHA workers across the country did not even get basic equipment such as masks, face shields, gloves and sanitizers during the pandemic. On top of being perennially underpaid, receiving just Rs. 3000 as honorarium for their regular work, they received a pittance of Rs. 1000 as ‘bonus’ for the extra work they performed during the pandemic. The surveillance carried out during the pandemic meant that ASHA workers would have to travel large distances. Yet not a single ASHA worker throughout the country has received any travelling allowance. Despite this, they have received scant recognition for the crucial role they performed as frontline workers.
The pathetic treatment that ASHA workers have endured throughout the pandemic is borne out in a survey that was carried out by Oxfam. The survey was conducted in the states of UP, Odisha, Bihar and Chhattisgarh. The results of the survey only confirm what trade unions have been saying since the beginning of the pandemic. The Oxfam survey found that at least 25 per cent of ASHA workers did not receive even basic necessities such as sanitizers; only 23 per cent received PPE body suits. Two- thirds of ASHA workers have not received the Covid bonus that was promised to them, while less than 50 per cent received monthly honorariums on time. During the pandemic, ASHA workers, because of the nature of their work, were often subjected to forms of discrimination. The survey revealed that 33 per cent of ASHA workers faced discrimination and violence.
The mental health of ASHA workers is never taken into consideration. For many of the women, their work as ASHA workers is directly linked to their survival. This means that they continue working under tremendous mental stress and trauma. ASHA workers who have lost children and family members are not even given paid leave to spend time grieving for those who have left them. But the working conditions and the socio-economic conditions from which ASHA workers hail make it impossible for them to quit their jobs. ASHA workers are quite often the only earning members in the family. No government has ever bothered to find out about the enormous amount of mental anxiety and stress that ASHA workers suffer.
Survey of ASHA Workers in Delhi
The national capital was one of the worst hit regions during the second wave of Covid, with nearly 30,000 cases and 450 deaths a day at its peak. With hospitals overflowing from the load of patients and shops running out of medicines, the ASHA workers were the frontline workers on the ground, monitoring patients daily. Even though the second wave has ebbed, they have not yet got their bonuses. If this is the case in the national capital, one can imagine the situation in the rest of the country. We have placed in this report two case studies of how during the Covid pandemic ASHA workers and their families were left to fend for themselves. They received absolutely zero support from the government. In both the cases, the government denies ASHA workers and their families any compensation. If an ASHA worker loses a family member, she does not get any support from the government; if an ASHA worker dies then the family does not get any compensation. The basic takeaway from this is that ASHA workers and their families have had to fend for themselves during the pandemic, despite ASHA workers being frontline workers.
To highlight the apathy with which they are regarded, the Delhi ASHA Kamgaar Union (DAKU) affiliated to All India Central Council of Trade Unions (AICCTU) conducted a sample survey of over 200 ASHA workers across 10 dispensaries in Delhi, covering around 20 localities. The findings of the survey paint a stark picture of the underpaid and exploitative working conditions that ASHA workers have to face day in and day out. It also shows that scant respect is paid to the labour of ASHA workers who work in undignified work conditions. The important findings of the survey are as follows:
Nearly all the respondent ASHA workers said they have no fixed working hours and are on call 24x7, which means they are perennially on standby mode to respond to any emergency. While they are on call throughout the day, they receive no allowance for this.
86 per cent of the respondents said they do not receive a fixed remuneration for the work they do. This is despite the fact that ASHA workers who were surveyed had an average work experience of 6.5 years working as ASHA workers. This clearly means that the problem of not receiving any fixed remuneration is a long standing one.
Most ASHA workers are supposed to receive Rs. 3000 per month as honorarium. This is much lower than the legally mandated minimum wages for workers. The sheer cruelty of this becomes starker when seen along with the finding of the survey that 30 per cent of the respondents said they are the only earning member in the family, which means their family survives on the Rs. 3000 they earn as honorarium.
In addition to the pittance they receive as pay, 66 per cent of ASHA workers surveyed said some amount is regularly deducted from their monthly pay on some pretext or the other.
All ASHA workers said they performed duties other than child health and maternal health care during the pandemic. They were asked to monitor home isolation and conduct surveys during the pandemic.
On an average, each ASHA workers covered 550 households as part of their work during the Covid pandemic, performing a variety of tasks. For this work, they received an average of Rs. 180 per ASHA worker. This shows that the remuneration paid to ASHA workers is completely arbitrary and irregular.
90 per cent of the respondents said there are no restrooms available for their use in the dispensaries.
About 45 per cent of ASHA workers said they regularly face misbehaviour and harassment from their superiors at their workplace.
85 per cent of respondents said they did not receive any gloves. 67 per cent said did not receive any mask and 75 per cent said they did not get any sanitiser to perform their work related to the coronavirus.
Family members of many ASHA workers were infected with the virus both in the first and the second wave. However, barring a few exceptions, ASHA workers got no help from the government for their treatment.
While ASHA workers are supposed to be paid Rs. 1000 as Covid allowance, which in itself is a criminally low remuneration, many do not get that regularly. In the survey, it was found among the respondents that only 30 per cent of ASHA workers received the Covid allowance regularly.
From the above findings, a clear picture emerges of the underpaid and exploitative nature of the work that ASHA workers do. Trade unions of ASHA workers and trade unions in general have been saying it for years that ASHA workers are one of the most underpaid and overexploited members of the working class.
Noorma Naaz was an ASHA worker working at the Mustafabad dispensary in North East Delhi. She hailed from a lower middle-class family. Noorma Naaz succumbed to Covid on 24 April 2021 at the height of the second wave of Covid while performing her duties as an ASHA worker.
Naaz’s family informed DAKU that when she received the vaccine, she was a bit hesitant because she had an artificial valve in her heart. Doctors told her not to worry and advised her take the vaccine, after which she took the shot. A few days later, she started feeling unwell and realised that her blood was clotting. The doctors at GB Pant Hospital told her that she needs a new valve in her heart due to the clotting that had happened. While preparing her for surgery, she took a Covid test and found that she was positive and was told to go the Covid ward. On seeing the pathetic situation of the Covid ward, where patients were sharing beds with dead bodies, her family brought her home. When her condition worsened, her family, like many others in Delhi, scoured nearly the entire city to look for an oxygen cylinder and then oxygen itself. By the time they managed to make arrangements, it was too late.
While the Delhi government had announced that any frontline worker who died during the second wave would get Rs 1 crore as compensation, Naaz’s family is still waiting for any help, monetary or otherwise, from the government. She has three young children aged 14, 10 and 8 respectively. Her husband told DAKU representatives who visited the family that not a single person from the dispensary where she worked called to find out how she was doing or offered to help. The family was left to manage the horrific situation on their own. After her death, Naaz’s husband has visited the dispensary many times to ask if they would get any compensation so that her children’s future can be secured. He has not received any answers from them as of now.
Delhi ASHA Kamgaars Union has written multiple times to the Delhi Health Minister and Chief Minister asking them to give Rs 1 crore to Noorma Naaz’s family as per the announced policy, but till now there is just silence.
Underpaid at Work! Unrecognized at Home!
Most ASHA workers without exception also have to do the bulk of the work necessary to run a household. But this never gets counted as part of the work they do. In fact, the work at home which includes an equally mindboggling number of tasks such as cooking, cleaning, looking after children and the elderly and many others is never even taken in to account while considering the work hours of ASHA workers. As a result, it is just assumed that women ASHA workers will be available throughout the day to attend to patients. And like the work of ASHA workers at home is never paid and recognized, their work as ASHA workers is never ‘done’ and poorly paid. This is the case with women across the country. As the economist Jayati Ghosh has observed, the work of ASHA workers is never considered work and hence they are paid an honorarium, a kind of payment which is usually paid for working on a part-time basis. But as we know, ASHA workers are on call 24*7 akin to any frontline health worker. Nevertheless, they are not considered employees and hence they are not paid a salary. It is indeed ironic that the ASHA scheme, which was touted as India’s answer to the problem of unequal access to health care, has ended up creating another system of inequality where more than 10 lakh women across the country work 24x7 without a break and are paid barely Rs.50 a day.
Since ASHA workers are considered part-time workers, they are not taken seriously by doctors in the various dispensaries where they work. The results of the survey in Delhi show us that ASHA workers regularly face humiliations at the hands of medical staff in dispensaries. The work done by them is considered unimportant and they are considered fair game. This is evident from the fact that dispensaries do not have toilets which ASHA workers can use.
ASHA Workers Struggle in Delhi
The Delhi ASHA Kamgaar Union, while highlighting the appalling treatment and work conditions of ASHA workers in Delhi, has also been engaged in providing ASHA workers safety kits. During the second wave, the DAKU distributed safety kits to at least 500 ASHA workers in Delhi. In cases where workers were facing acute problems in the family, ASHA workers were also given ration kits to help them tide over distressing times. The Union has held protest demonstrations across the city in various dispensaries, raising their basic demands with both the State and Central governments. The Delhi ASHA Kamgaar Union has written to the Health Minister and Chief Minister of Delhi and also to the Union Health Ministry about their demands. A delegation has also met Delhi MLA Dilip Pandey, asking him to facilitate a dialogue of ASHA workers with Health Minister and Chief Minister. The ASHA workers are still waiting to hear from the government.
Prime Minister Modi is very fond of holding his Mann Ki Baat, but rarely does he listen to the Mann Ki Baat of citizens. ASHA workers in Delhi have been undertaking a campaign of sending postcards to the Prime Minster with their Mann Ki Baat, listing out the demands that they have been making for a long time and telling the PM that they have had enough and their rights should be ensured. The demands being raised by the ASHA workers are as follows:
ASHA means hope in Hindi. In rural areas and working-class localities in large cities, ASHA workers are literally bringers of hope as they are the first to be contacted by people in case of a medical emergency. This is because people are familiar with ASHA workers who they meet nearly on a daily basis. But our governments’ treatment of ASHA workers is nearly inhuman and the Covid pandemic has proven that beyond doubt. Despite being dubbed as frontline workers, they and their families are left to fend for themselves. ASHA workers do not need flowers showered on them from helicopters as part of a political gimmick. They are demanding and they should be granted their right to dignified pay and work conditions.
- ASHA workers should be given the status of Govt employees.
- ASHA workers should receive a minimum pay of Rs. 26,000/- per month.
- Family of ASHA worker Noorma Naaz who died during the second wave in Delhi should receive rightful compensation.
- ASHA workers must be provided with fully paid maternity leave and medical leave.
- The additional corona allowance must be immediately disbursed to ASHAs.
- ASHA workers should receive Rs. 10,000/- per month as Corona allowance.
- To prevent sexual harassment at workplace of ASHAs there should be a district level gender cell.
- ASHA workers should not be subjected to humiliation and insults in dispensaries. Circular should be issued to all officials to prevent this.
- There should be a facility like a ‘common room’ for ASHAs in all dispensaries, where ASHA can sit.
- Working hours of ASHAs must be specified and the number of tasks to be done by ASHAs must be reasonable.
- Family members of ASHAs should receive free health treatment.
- Full payment should be made to ASHAs who have not been able to work during the Covid pandemic due to being infected with Covid.
- Points based incentive system for ASHAs should end. ν