Why ASHA Workers should receive Fixed Salaries

Abolishment of performance-based incentives for the horde of healthcare services ASHAs offer to the nation is a fair demand.

One million ASHA workers across the length and breadth of the country form the backbone of India’s primary healthcare system. They have helped eradicate polio and drastically reduced infant and maternal mortality rates. The country relies on the wonderwomen workforce for 71 public health programmes.

Creation of Accredited Social Health Activists or ASHAs in 2005 was a core strategy of the National Rural Health Mission to address shortcoming in healthcare infrastructure and manpower in rural areas. ASHAs act as an interface between the community and the public health system. Their key duties revolve around improving maternal & child health and containing communicable diseases. They are regarded as community health volunteers who have part-time duties for which they receive performance-based incentives. They are not covered by state governments' minimum wage legislation.

From contributing a few hours a day 2-3 times a week, ASHA responsibilities have grown over the years. However, remuneration hasn’t. In fact, underpayment, non-payments and delay in payments have been key reasons for their resentment against Government for years now. The most basic and crucial request that ASHA workers around the country have had is appropriate pay that complements their work hours and extra duties.

Too much Work

During COVID, the work load has multiplied manifold. Nagalakshmi, State Secretary, ASHA Union, All India Trade Union Congress (AIUTUC), Karnataka, states, “We visit homes to educate families about COVID, inform the Gram Panchayat and Health Department about new arrivals. We provide services at any time we’re called— we submit everyday reports about quarantined people; if anyone gets symptoms, we send samples for lab tests and take them for testing. We’ve screened a huge number of people, especially lakhs of children during the SSLC examination. The ASHAs from our state have surveyed around 1.6 crore houses during COVID. A part of our work also involves collecting information about households  the number of people with chronic illnesses, the number of kids in households etc as part of their vulnerability mapping survey. On our morning and evening rounds, we ask people not to be seen in groups outside.”

Too Little Pay

For the extensive list of COVID-related duties, a COVID incentive of INR1000 was promised by the GOI on 20 April, 2020. In a survey by Oxfam India conducted last month, 64 per cent of ASHAs claim to have received no incentives for the COVID-related responsibilities undertaken by them.

Banda Praveena is an ASHA from Telangana. She visits about 20 households a day for screening. ”Despite being overworked during COVID and attending night calls, we are getting a a paltry pay. We hardly get Rs 3000 or sometimes Rs 5,000. It’s been really difficult for us,”

Dhanya is an ASHA worker from Thiruvananthapuram. She’s on duty 8 hours a day. She not only visits homes of people (around 13 a day), but also visits fishermen/fisherwomen at their work places. At night, she receives calls and has to attend to deliveries, address new born baby problems and do quarantine work on call. For the extra work she’s been doing, she gets paid a paltry Rs 5000 honorarium and Rs 2000 incentive.

Both Dhanya and Banda want a fixed salary of Rs 10,000. "The current payment isn’t enough for the work we do,” says Banda.

In Karnataka, the workers receive an honorarium of Rs 4000 each from the state Government,. Their total pay comes up to Rs 7500 or Rs 8000 per head today (including the performance-based payment they receive), but a new digital system is undermining their pay.

Issues with ASHA Soft

"Our payment is linked through the ASHA Soft software,” states Nagalaxmi. In 2016, the government introduced Asha Soft, a web portal linked to the mother-child tracking system to make it easier to pay ASHAs. However, it is making life harder for the foot soldiers due to issues such as uninterrupted power, computer operation knowledge and Internet facility. "We get paid according to the entries in the online portal for each service rendered. But some tasks don’t get updated on the software and many mistakes happen during this process. Hence, we’re asking for the termination of performance-based payment which involves using the ASHA Soft. We want Rs 5,000 or 6,000. But with the software issue, we receive only Rs 1500 or Rs 2000. Overall, including the honorarium, our work should ideally give us Rs 10,000 or 11,000. We’re want a fixed salary. There is also a huge back log of payment because of the dysfunctional ASHA Soft app and many workers still have to be paid their old dues.”

The Many Challenges with Performance-based Incentive System

In September 2018, Prime Minister Narendra Modi had announced an increase in incentives for a few recurring activities. For example, from INR 100 to Rs 300 for maintaining the village health register. But health activists and ASHAs have criticised this proposal. ASHAs have demanded a fixed minimum monthly salary (varies from state to state) for years. Along with insurance cover, pension, and making ASHAs permanent workers.

A Vistara report funded by USAID, revealed that there are other challenges with this incentive system, that includes; no or less advance money at the facility, delay in the approval process, signing authority not being available and delay in payment by ANM; neglect of services that are not incentivised; and most importantly compensation not being met with their expectations. "It is not feasible to make ASHAs true unpaid volunteers. In addition, the amount of work that ASHAs are expected to complete, including record-keeping, seems to be expanding without a corresponding increase in compensation,” quotes the report.

Victims of Neglect and Violence in COVID times

ASHAs' health have also been on the line. They have not been provided with adequate PPE, be it protective masks or enough sanitizers. "So many ASHAs are working in containment zones without PPE kits,” complains Nagalakshmi. A Oxfam India survey confirms her claim. It shows that only 75 per cent ASHA workers were provided with masks, and only 62 per cent received gloves to perform their duties; just 23 per cent workers have received hazmat or bodysuits.

Furthermore, they have been victims of violence. "Initially, people thought we were there for the CAA survey, and fought with us. When migrant workers started going home, we were targeted by people and were not allowed inside homes. We’ve also had many cases of drunk people attacking us.” ASHA workers from Ludhiana faced harassment from residents, refusing to open doors, and also stopping them from pasting quarantine stickers. In Telangana, a coronavirus patient attacked two ASHA workers who asked him to be in quarantine as he tested positive.

Unkept Promises

On March 26, Finance minister Nirmala Sitharaman announced that the GOI will provide insurance cover of Rs 50 lakh per person to frontline health workers, which also includes ASHA workers.

In Maharashtra alone, 319 ASHAs have contacted COVID and were not able to claim the insurance cover. Also, the government also revealed that it had no data on the number of deaths amongst healthcare workforce. More than 20 ASHAs have died in the COVID pandemic and their families have not compensated.

Demanding Basic Rights

Hence it is not surprising that the protests have seen a new intensity where recently six lakh ASHA workers took to the streets for a two-day nationwide protest from August 7-8 in demand for fair pay, job recognition, social security and proper protective equipment. The response from state governments has been varied. Haryana and Delhi filed police cases and Madhya Pradesh threatened dismissal.

Without the ASHA army, the Indian primary health system will no doubt cripple. It’s high time the authorities listen, understand and make amends to accommodate their basic needs.