The women of ASHA: overworked, underpaid and on the edge of breakdown Premium

ASHA workers: Women health workers in India, facing challenges of care work, health risks, and systemic neglect

There’s a saying in the Chhattisgarhi dialect. Sukh mein sab hain, dukh mein Mitanin. Everyone is there in times of joy, but in sorrow, there are only Mitanins. The word translates to ‘friends’. A friendship, between women, one with the promise of compassion. In 2002, Mitanins also came to symbolise care, when the newly-formed State of Chhattisgarh designated women to play the role of community health workers. They were advocates for resource-deficient communities, friendly faces of a distant health system, agents of both change and care work.

Mitanins inspired the ASHA framework three years later. The Accredited Social Health Activist – a saree-clad cadre of almost 10 lakh women today – is a friend. Her care work dictates the reach and success of India’s health schemes. But agents of change tire too. Every ASHA logs in a ‘triple shift’, spread out between the home, community and health centres. Overworked and underpaid, they are caught in a frenzied rhythm: many do not eat well and sleep enough, and are at risk of anaemia, malnutrition and non-communicable diseases, found a new study supported by the Amit Sengupta Fellowship on Human Rights. It documented the limited autonomy the health workers have over their time, money and well-being. 

Experts place the ASHAs’ triple burden along an axis of power inequities – where gender, caste, and informal economy intersect. As women ‘volunteers’, and not designated health care workers, ASHAs experiences cut across “layers of marginalisation”, says Bijoya Roy, a public health researcher at the Centre for Women’s Development Studies. There is an economic, physical and psychological violence embedded in their role, crafted carefully by a system that refuses to assign value to their labour. “ASHAs provide care, but they are not cared for by anyone, not by the system in any way.” It is only during the recent Interim Budget that the Central government announced its decision to provide free health insurance cover for all ASHAs and Anganwadi workers and helpers under the Ayushman Bharat Scheme. In 2018, the Ministry of Health and Family Welfare approved an ASHA benefit package, providing coverage for accidents, deaths and disability.

The survey, conducted during COVID-19, traced the lives of 40 ASHAs in Phanda block in Bhopal. Day starts at dawn for many. They cook, fetch water, complete other chores, and soon begin visiting houses in the community. Meals are erratic and irregular: almost 30% of ASHAs said they do not have time to eat in the morning; some carry food for lunch, while others say they were forced to purchase from the market . About 13% of ASHAs said they do not eat anything the whole day. Back home, the women said they were the last to eat their meals in the family.

Almost half of the ASHAs also do not get enough sleep or rest. “The ASHA has a triple burden that all women workers carry,” explained Vandana Prasad, a public health professional associated with Public Health Resource Network. “She is doing housework, childcare, and looking after all homes and families for the health system – that too at very poor remuneration.” In Phanda, more than half were married at the age of 18-20 years, and about 50% of the ASHAs had their first child before 25. 

Outside of homes, the duties under their umbrella of work have expanded too: it started with maternal and child health, and now includes vaccination follow-ups, data logging, learning palliative care, reporting domestic violence cases, providing mental health support, and more. “In the name of shifting work, we are adding to the burden on volunteers who are underpaid and overworked,” remarks Dr. Roy.

Extreme weather conditions add a degree of precarity. ASHAs are on their feet or use a cycle during peak humidity and heat. Reports suggest the occupational hazards of working through heat waves or erratic weather will imperil the informal labour force. Extreme heat also creates a ‘double burden’ for women, according to an Adrienne Arsht-Rockefeller Foundation Resilience Center report. They are more vulnerable to getting sick from heat, while being responsible for providing paid and unpaid care work. Deteriorating environmental conditions alter their site of work, but “there is little discussion around changing the timing of work” or offering them protective shields, Dr. Roy said. Some States offer raincoats, umbrellas and cycles to ASHAs, but policy needs to become more conscious of their needs, she adds.