A Tough Pill to Swallow

Dr. Dhairya Shrivastava

By Dr. Dhairya Shrivastava, MBBS, MBA

Dr Dhairya Shrivastava discusses the situation of ASHA workers in India in her Two-part series “Straightening our Spines” Part 1

Straightening our Spines Part 1

This mini-series is about how the Indian healthcare system needs to rejuvenate and bolster its basic building blocks to be prepared for future emergencies.


As grassroot level workers serve as the infantry for tackling any health crises, in Part 1 I will talk about the ASHA workers (or ASHAs) in India and how the COVID-19 pandemic aggravated their already dismal conditions.

Who are ASHA workers?

ASHA stands for Accredited Social Health Activist, and the transliteration of the acronym ‘ASHA’ stands for Hope in Hindi. The role of ASHA workers was created in 2005 by the government’s Ministry of Health and Family Welfare departments under the National Rural Health Mission. ASHA workers are primarily local women within a village who bridge the villagers with the institutional healthcare system. Hence, ASHAs serve as the first line health workers in Indian villages for all healthcare related activities, like disease awareness programs, vaccination drives, reproductive and child health programs, etc. Currently, there are about a million ASHAs in the country. The ASHAs serve a pivotal role for community-level interventions. It is the largest community health worker programme globally and has proven to be effective in reaching its aim.

Onslaught of the pandemic…

Regardless of class, caste, or gender, the pandemic wrought havoc to all Indians. Issues like misinformation about diseases and vaccinations — which contribute to lost of trust in the institutional healthcare infrastructure — are worsening in rural areas. Moreover, reluctance to undergo testing and treatment have made rural populations more vulnerable to the virus.


For ASHA workers, the situation has been very grim, as wages have been delayed, compensation has been lowered, and COVID deaths in the workforce have been given meagre reward. Behanbox carried out a study in 10 states of India, which showed that work hours had doubled for frontline workers fighting the COVID-19 crisis. The study also highlighted how the income of ASHA workers had fallen by a margin of INR 3000-5000 in the state of Telangana during the pandemic. This happened because ASHA workers receive a part of their income from the number of immunizations they conduct, but this routine work was suspended in lieu of the pandemic. In addition, in the study, over 31% of workers said they had not received their COVID-19 incentives from the government.


Furthermore, many ASHAs, who were themselves working in a primary healthcare centre, were unable to find beds during the deadly second wave of the pandemic (March to May 2020 in India) and unfortunately succumbed to their illness. In Karnataka, one of the states of India, the union of ASHA workers has said that only 2 out of 16 (who died due to COVID-19) have received compensation.


The pandemic has also compounded their responsibilities. Conducting COVID-19 tests and checking home-isolated patients’ condition has been added on top of their existing responsibilities. The role of ASHA is semi-voluntary in nature, but their meagre wages are not fair, particularly considering their impact. 


As renumeration was delayed, ASHA workers bore their own expenses: buying smartphones for their children’s education as well as protective gear for doing their job. The continuous apathy towards their dismal working conditions has led some ASHA workers to join the union for organizing protests. These protests have mostly been for one day and have also led to a dip in the rate of COVID-19 vaccinations.

ASHA workers protesting the delay in wages; Source: The Leaflet

About time…

Rising omicron cases, coupled with a tired frontline workforce, does not paint a hopeful picture. ASHA workers constitute an elementary part of the healthcare ecosystem in India. With many key state elections around the corner for India, it is high time that governments start recognizing ASHA workers’ concerns and taking action to rectify the situation.

What's next on A Tough Pill To Swallow

The second part of the miniseries will talk about yet another necessity currently missing in the Indian healthcare system: a safe working environment for healthcare workers.

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