India’s army of unrecognised, unpaid female health workersBMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n2509 (Published 22 October 2021) Cite this as: BMJ 2021;375:n2509
When Netradipa Patil met 9 month old Riya (not her real name) she was perplexed. “Her vaccination card was half empty,” she remembers. Under India’s universal immunisation programme, Riya should have received at least 10 doses of multiple vaccines by then.
Riya was the fourth girl child in the family, something that gave a clue for Patil to reach the truth. “The family wanted a male child. The bias was so strong that they wouldn’t even get her vaccinated.”
Patil kept Riya’s vaccination card for the next five years and ensured all the doses were administered on time. Today, seven years later, Riya is not just in better health but goes to school and is treated with respect. “No child should be left unvaccinated. That’s what we strive for,” she says.
Patil is an accredited social health activist (ASHA), part of an all-female group of low paid community health workers who have become an essential part of India’s rural healthcare workforce. There are over a million of these all-female health workers nationwide. Patil represents around 3000 of them as the head of the ASHA union in Kolhapur, a city in the western state of Maharashtra, India’s second most populous state and the one with the highest number of covid-19 infections in the country.
ASHAs were first appointed in 2006 to fill the gaps in public healthcare in 18 high profile states. The government’s 2006 National Rural Health Mission—a plan to improve access to and quality of care in rural areas—declared that there should be one ASHA for every 1000 citizens, and the service expanded to the entire country in 2009. Today, there are 1 047 324 ASHAs,1 making it one of the most extensive community health programmes worldwide.2
Yet ASHAs are not recognised as full professional health workers, not least by the government, which defines them as “honorary volunteers.”3
Their job descriptions are loose, often leaving them responsible for over 70 varied tasks,4 including ensuring safer pregnancies, counselling women on birth preparedness, providing antenatal and postnatal care, providing medicines for common ailments, maintaining 77 health records, and community health awareness. The covid-19 pandemic has sorely tested what is still, after nearly two decades, an ad hoc system, leading to ASHAs striking over working conditions and lack of recognition.
Overburdened and unpaid
In March 2020, India’s health ministry tasked ASHAs with surveying their communities to identify potential covid-19 cases. They were expected to ensure that any suspected cases were tested, arrange medical facilities for those that tested positive, and ensure they completed their quarantine, while also raising community awareness of the disease and reporting case numbers to the supervisory medical officers who oversee their work. ASHAs, like other medical workers, have faced physical attacks and verbal abuse from a public weary and fearful of the ongoing pandemic and restrictions.5
They are still not considered to be full time workers, with a monthly income ranging from £35 to £45 in Maharashtra state. (For comparison, in rural Maharashtra, the starting pay for entry level medical officers is £550 a month, increasing with specialisation and experience; for nurses, it starts at around £250 a month.)
With their added covid-19 duties ASHAs are promised an extra £10 a month. But a report from the investigative journalism site Behanbox found that in several districts ASHAs hadn’t been paid. ASHAs who The BMJ spoke to said officials keep telling them they haven’t received funds from the central government and so don’t have the money to pay.
“Many ASHAs have worked 12 hours a day for over 400 days without a day off. Yet, they aren’t even given any medical insurance,” says Patil. Up until January 2021, the point at which the Indian Health Ministry stopped issuing official figures, 44 ASHAs had officially died from covid-19.6
It is these conditions that forced over 70 000 ASHAs across Maharashtra to go on an indefinite strike on 15 June 2021.7 Some of their demands included the legal status of full professional healthcare workers, a rise in their salary, and fair compensation for the families of ASHAs whose family members died from covid-19.
After nine days of strike action, the state government agreed to meet some of their demands and raised the monthly payments for ASHAs by £10 and the covid-19 duty pay by £5 a month, starting on 1 July. However, since then nothing has changed. “This hasn’t been done even today as we haven’t received our pay for over three months now. They are just making false promises,” says Patil.
“During the strike, vaccination came to a halt in several villages, and the number of covid cases kept increasing. The government knows how important our work is, but they will never acknowledge this,” she adds.
Filling a gap
ASHAs have spent a decade building bonds with the community. For 833 million Indians who live in rural areas, there are just 810 district hospitals, 155 404 sub-health centres, 24 918 public health centres, and 5183 community health centres to serve them8; some are in areas hours away from where people actually live.9 This makes it even more important to have community health workers who reach every part of the population.
Nowhere is the effect more prominent than in infant and maternal mortality. Fifteen years of ASHAs’ services has helped bring down India’s maternal mortality rate from 540 deaths per 100 000 live births in 1998-9910 to just 113 per 100 000 in 2016-1811 (box 1).
Vivek Joshi, medical officer of Ghalwad primary health centre in Maharashtra, also highlights the problem of illegal prenatal sex determination. “Several families don’t reveal pregnancy till they get a sex determination test. In [the] case it’s a boy, they inform us, and if not, they secretly abort the child.
“Since ASHAs know their community extensively, they keep an eye on such families and help save several girl children,” says Joshi. “ASHAs are not just the finest healthcare workers, but are good investigators as well,” he says, “The entire rural healthcare system will collapse if they stop working, yet what they are paid is negligible.”
Patil says she’s proud of the role her profession has played in saving lives. Now she wants their lives to be protected equally, and for their contributions to be acknowledged formally by the government.
Many ASHAs continue to work even if they contract covid-19 or are still suffering from the after effects. Vishranti Kamble, another ASHA working in Maharashtra, resumed work despite still suffering from fatigue 15 days after testing positive for covid-19. “The cases were increasing rapidly, and I couldn’t take a leave. Despite the system failing us, we work every day to ensure none of the community members die.” She says she worked 410 consecutive days during the pandemic.
Several ASHAs have also been diagnosed as having mental health problems, hypotension and hypertension, and other diseases.12
The non-governmental organisation Women in Global Health suggests that their work should be recognised by both the community and the government through financial and non-financial incentives, along with support systems for their mental and physical wellbeing.13 And the health ministry’s own covid-19 service delivery report advocates timely payment for ASHAs.14
However, BehanBox found that in all but six of India’s 28 states, ASHA workers do not get a fixed monthly payment. Of 10 states they surveyed, 86% of ASHAs saw a dip in their income from March 2020. This is because ASHAs’ pay comprises a fixed payment of £20 a month from central government and performance based incentives based on the number of tasks completed. During the pandemic, ASHAs have struggled to complete a number of these tasks.
“We couldn’t organise community health awareness camps because of covid-19 restrictions, and the government deducted our pay for that without even considering how we had increased door-to-door visits to make people aware of covid-19 and other diseases,” says Patil.
Several protests by ASHAs have been made at regional and national levels since the pandemic began. These protests have achieved some success: a march on 15 September in Maharashtra led to officials clearing four months of payments that were pending for ASHAs from April to July 2021. “We will keep protesting until our demands are met,” says Patil.
How ASHAs slashed infant and maternal mortality
In 2011, India’s Ministry of Health launched the home based newborn care programme. The goal was to encourage safer institutional deliveries and look after the safety of conceiving woman and the newborn. ASHAs played a key part in this.
They were trained to monitor the newborn’s weight and behaviour every week till the 42nd day. They also counsel the family on maintaining hygiene, breastfeeding, and counter superstitions, such as the practice of putting oil in the child’s nose and ears or Kohl (a traditional cosmetic containing lead) to the eyes, all of which are harmful to the child. ASHAs also ensure the newborn gets a BCG vaccination and their first dose of the diphtheria, pertussis, and tetanus and oral polio vaccines. In 2018-9, over 900 000 ASHAs provided visits to 13 000 000 newborns.
Before the home based newborn care programme, “many newborns would die within 28 days,” says Patil.
As a result, the infant mortality rate fell from 69.039 per 1000 live births in 1999 to 28.257 in 2019.15 Moreover, India reported a steep decline in under 5s mortality rate from 109 deaths per 1000 live births in the five years before the 1992-93 survey to 50 deaths per 1000 live births in 2015-16.16 A 2019 study found that exposure to an ASHA led to a 28% increase in delivery at a health facility instead of home.2
“In addition to monthly visits, every ninth day of the month all pregnant women undergo a health check-up that includes monitoring blood sugar level, blood pressure, and other parameters,” says Patil. To avoid anaemia, women are given iron and folic acid tablets every month, for which ASHAs maintain a record.
“ASHAs are so close to the families that they even know if they are taking the medicines or not,” says Sachin Salave, a physician who works at Kolhapur’s Kerle sub-centre.
Patient consent not needed (patients anonymised, dead, or hypothetical).
Commissioning and peer review: Commissioned; not externally peer reviewed.
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.