India’s ASHA workers: Overworked, underpaid and exploited? Baseline health activists still struggle with delayed payments and no incentives
17, Sep 2021 | Adeeti Singh
As part of the government’s National Rural Health Mission (NRHM), a new group of baseline health workers called Accredited Social Health Activists (ASHA workers) was formed in 2005 to address health related demands of the rural population, especially women and children, who find it arduous to access basic health services.
The government guidelines laid down several responsibilities of ASHA workers which include creating awareness about health and its social determinants, mobilising the community towards local health planning, and increased utilisation and accountability of existing health services. This 2005 design recruited women as volunteers on honorariums to engage in tasks central to the functioning of the public health infrastructure, and promote good health practices.
Their role became even more critical in the Covid-19 pandemic era as they have been deployed to undertake additional work, like conducting door to door tests, monitoring the migrant workers, ensuring the adherence to Covid-19 protocols, as well as collecting data and reporting to the primary health centres across various states.
But the workload of ASHA workers is not directly proportional to the remuneration they receive, and they continue to be seen merely as volunteer service providers. The enormity of injustice does not end here, as they don’t fall under the ambit of the Minimum Wage Act, and don’t enjoy the maternity benefits and other schemes offered to regular government employees.
Meagre wage
In a written answer provided by Bharati Pravin Pawar, Minister of Health and Family Welfare, on July 23 this year to the Lok Sabha, it was revealed that ASHA workers receive a fixed monthly incentive of Rs. 2,000 for undertaking routine and recurring activities. Further to incentivise Covid-19 duty, the government decided to add an additional Rs. 1,000 per month under India’s Covid-19 Health System Preparedness and Emergency Response Package.
Different states have different incentives for ASHA workers, but there have been several strikes since the onset of the pandemic demanding sufficient and timely remuneration. For instance, Uttar Pradesh sanctioned Rs. 750 per month from the state budget and the average ASHA payment in the State is Rs. 4,270 per month. CJP’s interaction with hundreds of these women across the state reveals backlogs in payment of wages and often, withholding of payment, too. Bihar provides Rs. 1,000 per month apart from the fixed price fixed by the centre, so ASHAs in Bihar get Rs. 3,000 per month, Himachal Pradesh ASHAs get Rs. 2,000 per month, Uttarakhand ASHAs get Rs. 5,000 per annum and Rs. 1,000 per month.
Besides the range of monetary incentives to the ASHAs, on June 25, 2020, thousands of ASHA workers united, at the call of the All India Coordination Committee of ASHA Workers (CITU), and held a protest at various states, including Jammu and Kashmir, Punjab, Assam, Haryana, Madhya Pradesh, Maharashtra, Odisha, Gujarat, Andhra Pradesh and Kerala for regularisation as government workers, for adequate Covid kits (gloves, masks, sanitisers), additional incentive of Rs.25,000 per month for all contract and scheme workers, Rs. 50 lakhs insurance cover to all frontline workers, etc.
The same answer provided to the Lok Sabha in July this year also revealed that out of 10,47,324 ASHAs, a total of 109 have died due to Covid-19 till April of this year, across the nation, but the numbers could be arguably higher.
Going by the government records, Uttar Pradesh, Tamil Nadu, Sikkim, Manipur, Meghalaya, Mizoram, Nagaland, Puducherry, Himachal Pradesh, Ladakh, Lakshadweep, Andamans, Arunachal Pradesh, Dadar and Nagar Haveli, Daman and Diu and Assam have not recorded a single death of the health activists.
Covid-19 duty risks
In May this year, lakhs of Accredited Social Health Activists across the country reportedly protested and demanded their pending payments and protective gears like PPE kits and masks for themselves. The workers who have efficiently assisted the government in controlling the spread of the virus have raised their voices against inadequate facilities. Some workers have complained that they hadn’t been provided uniforms for the last three years and they are expected to travel door to door to check on home isolated patients but have not been provided for transport, food or water while attending duties and most were yet to be tested for Covid-19.
According to a NewsClick report, in Karnataka, D. Nagalakshmi, state secretary of the All-India United Trade Union Centre (AIUTUC) backed ASHA Workers’ Union said that the 42,000 workers have been waiting for their “honorarium” – Rs 4,000 – for the past two months.
Justice from the Courts?
The Bombay High Court was one of the first courts to recognise the importance of ASHA workers especially in the fight to combat Covid-19 and had directed the government to pay Rs. 200 per day instead of the fixed Rs. 1,000 per month. The application was filed on behalf of the Nagpur Municipal Corporation Employees Union in Subhash Jainarayan Zanwar Vs. Union of India and others, PIL No.10 of 2020), wherein they brought to the notice of the court the pathetic condition of the Accredited Social Health Activists.
They complained that appropriate remuneration was not being paid to the ASHA workers and the basic equipment for protection/security were not provided and further, even refreshments and tea, as also water from time to time, was not available to them. The insensitive Nagpur Municipal Corporation had gone a step ahead and filed an affidavit in the matter stating that there was no legal provision to provide food and refreshments to the ASHAs!
Justice Manish Pitale had said, “This Court finds that the ASHA workers, who are at the forefront of the war against COVID-19 and who are performing special duties, including door to door survey of houses during such crisis, are being treated in a most unfortunate manner by the Corporation. Even if the amounts of 1000/- per month and 1500/- ₹ 1000/- per month and that ₹ 1000/- per month and that per month i.e. total of 2500/- per month is being paid to ₹ 1000/- per month and that the ASHA workers, it is hardly sufficient for survival of such workers… It is distressing that those at the forefront of the war against COVID-19 are meted out with such treatment by the public authorities including the Corporation.”
How far have our courts helped?
Negligent efforts have been taken by the judiciary and the government to recognise the status of ASHAs as workers under the Industrial Act to avail the benefits of the Minimum Wages Act. The Minimum Wage Act that prescribes a minimum amount must be paid to an employee by the employer, as mentioned above, does not apply to ASHA or Anganwadi workers.
A big blow to Anganwadi workers was in 2006, when the Supreme Court Bench of Justices SB Sinha and Markandey Katju had held that Anganwadi workers engaged under the Integrated Child Development Service (ICDS) Programme are not entitled to minimum wages as the Minimum Wages Act is applicable only to ‘workmen’ in the industries. The Bench said the ICDS programme would not constitute an “industry” within the meaning of the Act and Anganwadi workers were not industrial workmen. (State Of Karnataka & Ors vs Ameerbi & Ors, Appeal Civ. No. 4953-4957 of 1998).
However, in State of Punjab and Others versus Jagjit Singh, Civ. Appeal No. 203 of 2013, the Supreme Court offered some relief for scheme workers where it ruled that all types of temporary workers and daily wagers are entitled to wage parity with the regular workers provided, if they perform similar work. Another important aspect of this judgment was that it had opined that a mere difference in nomenclature should not deprive an employee from being paid a similar wage that a permanent employee gets for the “same amount of work”.
Calling it “exploitative enslavement”, the court had said, “it is fallacious to determine artificial parameters to deny fruits of labour. An employee engaged for the same work, cannot be paid less than another, who performs the same duties and responsibilities. Certainly not, in a welfare state. Such an action besides being demeaning, strikes at the very foundation of human dignity. Any one, who is compelled to work at a lesser wage, does not do so voluntarily. He does so, to provide food and shelter to his family, at the cost of his self-respect and dignity, at the cost of his self-worth, and at the cost of his integrity. For he knows that his dependents would suffer immensely, if he does not accept the lesser wage.”
Almost 5 years after this judgment, ASHA workers continue to fight for their identity, demanding for a permanent worker status and surely, the pandemic has exacerbated their needs. The 45th session of the Indian Labour Conference (ILC), had also recommended that all scheme workers should be recognised as ‘workers’ and not as ‘volunteers’ or ‘honorary workers’. It was also suggested that the Anganwadi workers and ASHAs be covered under life and health insurance and all necessary amenities should be extended to the women. But the action taken report presented by the government at the 46th meeting of the Standing Labour Committee rejected each and every one of these demands except the demand for insurance scheme coverage.
In Oxfam’s Commitment to Reducing Inequality Report 2020, India ranked 154 in health spending, (fifth from the bottom). This infrastructurally reflects on the lack of enough amenities for the health workers that have been fighting tooth and nail to contain the pandemic. Despite being hailed as frontline workers and Covid-19 warriors, essential ASHA workers continue to work under unfortunate conditions.
According to ThePrint, a survey was conducted by Oxfam India and its partner organisation in Uttar Pradesh, Odisha, Bihar and Chhattisgarh, interviewing a total of 306 ASHA workers. The startling facts that emerged were that just 23 percent workers had received hazmat or bodysuits. 64 percent of them claimed to have received no incentives for the Covid-related responsibilities undertaken by them. Only 43 percent ASHAs had received their monthly honorariums on a regular basis, as of September last year.
Central government’s Pradhan Mantri Garib Kalyan Yojana that was meant to provide an insurance cover of Rs. 50 lakh per person to frontline healthcare workers, sanitation staff, paramedics and nurses, ASHA workers and doctors was known to only 38 percent ASHA workers across the 4 states.
Besides verbal applause and showering petals over hospitals through helicopters to motivate healthcare workers, the government should start with recognising the ASHA workers who have proved to be more than just volunteers, and to not look for interim measures to shore up the crumbling public healthcare system. Subsequently, inhumane working conditions, inadequate staffing, low compensation, unacceptable working, lack of basic amenities should be next on the agenda!
As India begins to recover from 15 months of a social and political crisis unleashed by mis-governance over the handling of the health emergency, will Indians learn lessons and join hands to campaign for better wage security and health conditions for our ASHA workers?
Image Courtesy: ASHA Workers in Delhi – Image from MOHFW Twitter
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