This year marks two decades since the launch of the Accredited Social Health Activist (ASHA) programme under the National Rural Health Mission (NRHM). Introduced in 2005, the programme aimed to create a network of community health workers to bridge the gap between the community and the formal healthcare system.
Today, there are around 10 lakh ASHA workers across India, playing a crucial role in delivering maternal and child healthcare, immunisation, and community health awareness. However, despite their indispensable contributions, ASHA workers remain among the most underpaid and overworked sections of India’s public health workforce, with no fixed salary, limited social security, and inadequate recognition.
ASHA workers are often the first point of contact for healthcare in rural India. They conduct home visits, provide antenatal and postnatal care, mobilise communities for immunisation drives, distribute essential medicines, and ensure institutional deliveries. During the COVID-19 pandemic, their responsibilities expanded to include contact tracing, public awareness campaigns, and assisting in vaccination efforts, often at great personal risk. Various studies over the last decade have shown that ASHAs have played a crucial role in improving maternal and child health practices and outcomes in India.
Despite this, ASHA workers are not classified as government employees but as ‘volunteers,’ which allows the state to deny them minimum wages, gratuity, and other employment benefits. Instead, they are paid through a system of incentives, which are often irregular and not commensurate to their work. The Union government provides ASHA workers a fixed monthly incentive of Rs 2,000 in addition to task-based incentives under various health schemes. For instance, they receive Rs. 300 per institutional delivery facilitated, Rs 500 for ensuring spacing of two years after marriage, incentives related to preventive and treatment measures for tuberculosis, vector-borne diseases and so on.
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The response to a recent question on honorarium paid to ASHA workers in the Lok Sabha (asked by G. Kumar Naik and responded to by minister of state Prataprao Jadhav, on February 7 this year), stated that, “The primary responsibility of strengthening public healthcare system, including support for ASHA workers lies with the respective State/UT Governments.”
This is a bit odd considering that ASHAs were appointed under a National Mission and therefore it would be expected that the union government would take greater responsibility. Nevertheless, it is the case that there is a wide variation in the incentives ASHAs receive across various states. Andhra Pradesh tops up from its own resources to ensure that ASHAs receive a fixed salary of Rs 10,000 while Kerala pays an additional Rs 6,000 per month, Telangana Rs 6,750 per month and Madhya Pradesh Rs 4,000 per month. A number of other states add amounts around Rs 1,000, either in the form of additional incentives linked to activities or as fixed honorarium.
While there are no separate pension or health benefits, an ASHA benefit package was introduced in 2018 which made ASHAs eligible for other government social security schemes such as the PM Jeevan Jyoti Beema Yojana for life insurance, PM Shram Yogi Maan Dhan for pensions (with 50% contribution by beneficiaries and 50% by the government) and PM-JAY (Ayushman Bharat) health insurance scheme.
ASHA workers protest in Delhi. Photo: Special arrangement
With increased incentives in most states and inclusion in some of these social security schemes. there has been significant improvement in the remuneration of ASHAs compared to where they started off. Yet, the earnings of ASHAs are still meagre relative to the work they do and they lack the dignity and recognition of being regular employees. ASHAs also face multiple risks while on the job, as they move from house to house and from their villages to health centres. There have been reports of violence and abuse, including sexual harassment, faced by ASHAs while on the job. There are no institutional forms of grievance redress and support for ASHA workers.
Unlike government employees, ASHA workers are not entitled to gratuity under the Payment of Gratuity Act, 1972. This has been a major point of contention, as many ASHA workers serve for decades with no retirement benefits. Court rulings on similar cases, such as the Supreme Court’s decision on gratuity for Anganwadi workers, provide a basis for legal demands, but the government has yet to recognise their right to retirement benefits. In a recent positive development, Andhra Pradesh has announced gratuity of Rs 1.5 lakh for ASHA workers who retire after completing 30 years of service and introduced 180 days of paid maternity leave. Hopefully other states will also follow suit.
It must also be recognised that these gains that ASHAs have made in different states have often been as a result of their collective action. Especially over the last five years ASHA workers’ unions have staged multiple protests, nationally as well as in various states. Despite these efforts, government responses have largely been limited to marginal increases in incentives rather than structural changes.
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ASHA workers in Kerala have been on strike for the last 20 days, with the issue creating an uproar in the media and the Assembly. While acknowledging that Kerala does make a higher contribution to ASHAs’ honorarium than most other states, it is also true that the ASHA worker demands of higher pay and retirement benefits is justified. The issue of central vs state contributions is relevant here and has to be discussed in the larger context of revenue sharing as well. As far as ASHA payments are concerned, the fact is that the central government contribution towards ASHA honorarium has not increased in seven years.
Two decades after the ASHA programme’s inception, it is clear that these workers form the backbone of India’s public health system. However, their continued exploitation reflects a deeper failure to recognise and value care work, which is predominantly performed by women. As India celebrates 20 years of the ASHA programme, it is time for policymakers to reflect on whether a nation that relies so heavily on these workers can afford to continue underpaying and undervaluing them. The struggle of ASHA workers is not just about wages – it is about justice, dignity, and the right to fair compensation for essential work.
Dipa Sinha is a development economist.
