ASHA workers are the backbone of India’s rural healthcare, but who has their back?

Sunita Gautam found purpose despite life throwing a curveball.

Her husband died when she was two months pregnant with her youngest son. For five years, she scraped by doing odd jobs, borrowing money, and asking for help. One day, a friend mentioned an Accredited Social Health Activist (ASHA) training programme at the local panchayat near Saharanpur, Uttar Pradesh, and she decided to attend it.

In 2018, she became an ASHA worker, and suddenly, the same village where she lived as a woman without agency now saw her as a didi (sister), a beti (daughter), and a lifeline to important social development parameters.

As with other ASHAs, Gautam isn’t just a healthcare provider, but an advocate, caregiver, and trusted confidante for her community members. In addition to her government-mandated healthcare duties, Gautam educates and empowers young girls in her community to tackle gender inequality, child marriage, and lack of education. She also provides leadership training and advocacy through Milan Foundation, a Delhi-based NGO.

Gautam and other ASHA workers serve as crucial intermediaries for NGOs, ensuring that grassroots programmes reach the most vulnerable populations. Their deep community trust, local knowledge, and extensive networks make them ideal partners for NGOs.

The greatest success of the ASHA programme—instituted in 2005 as part of the National Rural Health Mission (NRHM)—is that it removes the trust deficit that often exists between marginalised communities and government healthcare services. ASHA workers are traditionally selected from within the village or locality they serve.

However, Gautam does not have the luxury of slowing down. She often has to sprint into the night to help with a difficult birth in one home or a dying grandfather in another, and leaves the household responsibilities to her daughter. 

While her expenses pile up, Gautam has to constantly calculate how to make her measly honorarium stretch an entire month. She earns Rs 3,000 to Rs 5,000 monthly, depending on how many deliveries, TB cases, and immunisations she can log. ASHA workers are not classified as government employees but as ‘volunteers’, and lack formal employment status, pensions, and adequate salaries. For these reasons, ASHAs have repeatedly gone on strike in Maharashtra, Uttar Pradesh, Odisha, Delhi, West Bengal, and recently, Kerala. 

Gautam is the first responder for her village—but the question remains, who responds to her family’s needs?

Indispensable but unrecognised

In Kerala, over 26,000 ASHA workers are said to have not received their monthly honorarium of Rs 7,000 for at least two months, along with incentives of approximately Rs 5,000 each pending for three months. The workers are advocating for an increase in their monthly honorarium to Rs 21,000, in lieu of their extensive workload and responsibilities. They're also demanding a retirement benefit of Rs 5 lakh.

The Kerala government and the Centre are at loggerheads over fund disbursements as 60% of the funds come from the central government.

Varalakshmi, the Karnataka State Honorary President of Akshara Dasoha Union (affiliated with the All India United Trade Union Centre) and Karnataka State President of Centre of Indian Trade Unions, tells SocialStory, "The 46th Indian Labour Conference recommended that ASHA workers be recognised as workers, not honorary volunteers. Yet, the government continues to treat them as temporary scheme workers, denying them fair wages and statutory benefits." 

She points out that even if an ASHA worker dedicates months of labour to ensuring a woman receives antenatal care, her income is not guaranteed. If a pregnant woman fails to meet eligibility criteria for a government scheme or lacks proper documentation, the ASHA worker does not get paid.

“Many ASHAs cover 300-400 households. Their workload extends beyond healthcare—community surveys, nutrition tracking, and emergency assistance. But the government doesn’t see this as real labour,” says Varalakshmi. ASHAs, despite being the first point of contact for medical intervention in villages, continue to be employed on an incentive-based model.

Akshara Dasoha Union’s demands include Employee Provident Fund, Employees' State Insurance benefits, and essential work gear such as uniforms, gloves, scarves, and aprons for ASHAs Anganwadi and midday meal workers.

These issues were exacerbated during the pandemic when ASHA workers found themselves on the frontlines of a national health crisis, with no help. Fr. Teyol Machado SJ of Karnataka, who has worked for three decades in grassroots activism and community development, saw firsthand how these women held up public health while being systematically ignored during the COVID-19 pandemic.

“They were the ones most exposed to the virus, going door-to-door without proper safety equipment. No masks, no sanitisers. Whatever little they got, they had to beg for it at the local primary health centres, only to be scolded by doctors and nurses for taking supplies meant for ‘real’ healthcare workers,” narrates Fr. Teyol.

Worse still, whenever COVID-19 cases spiked in a region, ASHA workers were blamed. If a patient wasn’t tested in time or treatment wasn’t successful, they were held responsible—without resources, authority, or recognition, he says. He adds that in an even more troubling trend, political parties exploit ASHA workers, pressuring them to mobilise women for political rallies.

Radhika (name changed on request), an ASHA worker from Kerala, says she couldn’t afford to stop working during the pandemic despite testing positive for COVID-19. “I couldn’t rest. We had to make arrangements for vaccinations for everyone,” she recalls.

After several protests, Radhika says some of their pending honorariums and incentives until January 2025 have been finally paid but payments for February are still due.

A programme built on exploitation

The ASHA programme was designed to bridge the trust gap between rural communities and government healthcare. It has succeeded in doing that, but at what cost, ask workers and those advocating for their rights? 

These workers juggle pregnancy care, TB and HIV monitoring, immunisation drives, palliative care, and emergency response—all while navigating unpredictable wages, no pensions, and a lack of safety measures. The root of the issue lies in the scheme-based structure of their employment. When ASHA workers are not recognised as government employees but as volunteers, the state is able to exploit their labour while denying them formal protections. 

According to the National Health Systems Resource Centre, a premier think-tank for the Ministry of Health and Family Welfare, India had approximately 980,000 ASHA workers as of 2020, achieving a ratio of one ASHA per 979 rural residents. 

“When these many women are working in this field, they must at least be recognised as workers, right?” says Varalakshmi.