'Burnout, Breakdown and Burden': A Day in the Life of India's ASHA Women

"The government says women are safe, where are the women safe? We're being exploited in every way," said ASHA women.

“It’s like I have spent most of my life in a job where I expected a lot and got very little in return. I thought it would give me support in old age. Did I make the wrong decision?”

Almost 20 Years. No Fixed Salary.

For 59-year-old Kiran Pandey who is part of Accredited Social Health Activist (ASHA), colloquially called as ASHA didi or ASHA bahu, life has not been easy.

Yet, her life represents thousands of ASHA workers who staged the 'Kalambandh' dharna between February and March all over Uttar Pradesh ahead of Lok Sabha elections in April. 'Kalambandh' translates to 'penned down' or 'recorded.'

This is the first story in our two-part series on ASHA workers, looking into their life, struggles, demands and protests.

For the uninitiated, ASHAs play a pivotal role, acting as the first link or point of contact between the marginalised communities and the healthcare system, with a particular focus on women and children.

However, almost 20 years since the introduction of ASHA, deep fault lines in terms of fatigue, poor work-life balance, extremely low levels of compensation, lack of autonomy and recognition have emerged but hardly made it to mainstream news coverage.

As per Press Information Bureau 2020, there are 1.6 lakh ASHAs in Uttar Pradesh, but as per the ASHA women we spoke to, there are around 2.5 lakh ASHA ‘didis’ covering 75 districts in the state. The Quint spoke to nine such workers who are not just angry but also exhausted.

'Shift After Shift': All Work and No Pay

An ASHA worker since 2006, Pandey worked in Ghazipur till 2015. Now, she works in one of a Primary Health Centre (PHC) in Baraula, Sector 49 in the outskirts of Noida.

5:00 AM: With a small pouch across her waist, she carries a water bottle, condoms, pregnancy kits, medicine tablets such as Paracetamol, calcium and iron. Another bag includes her register and other papers.

"Most of the times we don't eat or eat very little in between. Most of us cannot afford to or don't have the privilege to get enough rest or sleep."

Pandey leaves from Roza Jalalpur in Noida with her younger son who drops her halfway through to the PHC.

Then, she takes an auto/e-rickshaw and travels till the PHC which takes another hour or so.

10:00 AM-2:00 PM: Pandey is inundated with checking children and pregnant women for the necessary tests. Sometimes, she rushes to either Lady Harding, Kanshi Ram, Safdarjung or another government hospital in the NCR if a pregnant woman is close to labour or needs a checkup.

This might take half the day or even two days.

The Quint visited a government hospital (also called 'COVID hospital') with Pandey where she had to meet a woman who had given birth a day before. 

We met another ASHA worker (Rural) Pramila Sharma, 49, from Saadatpur who was waiting, while an expecting mother she is responsible for, was in the labour room.

An ASHA since 2015, she was hesitant to speak at first. Then said, "Yahan lagne ke baad ghar ke kalesh tayyar hogaye. (Ever since we joined here, problems at home are ready). We want some respect and recognition. We're living on breadcrumbs."

Till 5:00 PM: Sometimes Pandey is at her Centre by now or at the hospital. If she is at her Centre, she will carry out the required surveys, to take stock of the children given ‘tikas,’ the children who are left, including the expecting mothers she has to take care of.

“If I reach by the evening, then I make a list of all the tikas and tests done. Sometimes, the supervisors or the seniors keep the chair for others inside and I have to sit outside.”

Pandey, who is almost 60, has trouble walking because of past leg injuries. By the evening, not having eaten properly or taken any break the entire day, she leaves for home.

It's a long way back home. The Quint travelled back to her place which takes almost two hours in the evenings, the roads are dug up and there is barely any lighting in the lanes.

After reaching home, Pandey said there are times when she gets a call, and she has to leave for work again.

“I will get a call for a mother’s delivery or some medical checkup and then leave home even without eating, drinking and rush all the way back at night,” she noted.

“I took care of a pregnant woman’s labour in February, yet my voucher is still pending, I haven't received any money from it.”

ASHA workers are responsible for caring for expecting mothers, their newborn child for 42-48 days, also called neonatal care. It is only after 9 months that they get paid.

“I work in an urban area and get Rs 400 at the end of the 9 months that I take care of the woman and child. ASHAs who work in rural areas get Rs 600."

Kiran Pandey, an ASHA to The Quint

Pandey’s travel fare comes to around Rs 240 in a day alone.

In 2005, the ASHA programme, touted as the world’s largest government-funded health insurance, was launched by the then Manmohan Singh-led government and is a key part of the National Rural Health Mission (NRHM).

However, all the ASHA women said that not much has changed since its inception.

"It was very difficult to take care of the children. It was hard to carry on but harder to stay in the same situation. When I joined, I was told the work entails some medical tests and I got 50-100 Rs for it. From one task we have progressed to a 100."

Kiran Pandey to The Quint

Pandey joined because after her husband passed away in 2011, she went into depression and faced financial and property issues back home. “Jar Juru aur Zameen” (money, women and property) as she called it.

“Life hasn’t been easier even with this work. Now, I am just exhausted, overworked and sleep-deprived most days even as I try to manage my BP and medicines.”

Pandey’s two sons are now working and contribute to her household expenses.

'Har Behen Ka Wahi Dukh'

What started as neonatal and maternal healthcare, now includes vaccinations, government programmes, data logging and surveys, reporting domestic violence cases, providing mental health support — while also taking care of home and domestic chores.

Another ASHA, Kaushalya Rawat, 44, now has five children and distinctly remembers joining the programme on 17 July 2008. She is the district head of their Union (ASHA Bahu Kalyan Samiti), Mohanlalganj in UP.

"I had joined to ASHA to help pregnant women. At that point, I was told that I'll have to take care of them and their babies. I was not employed for all the other tasks. Now. whatever work that government has, they impose it on us, har behen ka yahi dukh hain (Every sister has the same pain)," remarked Rawat.

Since all ASHAs work on task-based incentives and payments, their income varies, the standard wage is somewhere between Rs 3,000-5,000 per month.

"My husband is a labourer and I have 5 children, how do I run my house with such less money? All of us want to give good education to our children and get them settled. How will I get them to a good school when there is no money?" asked a furious Rawat.

Most ASHA workers belong to OBC, SC and ST communities, as the women corroborated to The Quint. This 2019 study on the impact of ASHA program stated:

"In areas where active ASHA activity was reported, the poorest women, and women belonging to scheduled castes and other backward castes, had the highest odds of receiving ASHA services."

Over 30% rural women reported ASHA services as compared to 10% among urban women.

How Do ASHA Workers Get Paid?

Essentially, ASHAs receive around Rs 1,850-2,000 as an incentive every month, this has been constant since years and has not increased.

Rawat added, "Kehete hai mahila surakshit hai, kaha mahila surakshit hai? mahila ka toh shoshan kiya jaarha hain har taraf se.” (They say women are safe, where are the women safe? We are being exploited in every way).

Some ASHA workers feel their situation is worse than a labourer who works under MNREGA.

“Even MNREGA workers have a fixed salary. We are slogging all day and night then get Rs 100 and Rs 75 for taking part in Filaria and Polio programmes, respectively," ASHAs stated.

When an ASHA worker covers 150 houses for polio vaccination, then they receive Rs 75 for the same. 

The following is a list of tasks that have been assigned to them, however, ASHAs claim that they only get money for less than half of these.

Hailing from Sultanpur, Seema Singh, 45, is the Union President.

She stated that there are around 50 tasks but money is only given for 10 of them and the payment usually takes a month or two to arrive.

Singh, the union head said that she got into the programme through the Gram Sabha when she was 23 years old. At that point, her daughter was 7 months old. 

“I had thought it would be good, ASHA's work is very important, to be there for everyone and hold the community together and check everyone's health 24x7. I thought it would become a permanent job in future."

Pointing out the inflation of cost of living, she highlighted how difficult it has become for ASHAs to manage expenses and their health.

These issues, including not being recognised as an official health worker, are what drove Singh and other women like her to organise the Union.

"Kadi se kadi jodkar banaya hain Union," ASHA women stated.

Echoing their sentiments, Lucknow's Sarita Yadav, 40, called their profession "bandhua mazdoori" (bonded labor).

"We're hardly able to do anything at home. How do we function and take care of our homes on a daily basis when we don't get any time?" said Yadav.

Calling them the “the first-level health worker,” Dr Anant Bhan, a researcher in health policy and global health, explained that ASHA’s started as a voluntary cadre initially only meant for neonatal and maternal healthcare.

This explains why the structure is in line with a voluntary mechanism, inspired by the Mitanin programme in Chhattisgarh.

He stated that a good question to ask is: Is the voluntary approach still a good approach then?

"Role of the ASHAs have kept increasing and with the Coivd-19 pandemic we saw that they became the last leg of the health system. The real challenge and need then becomes to changing it all into a formal system that align with the responsibilities given. Does the delay in payments then align with the kind of role ASHs have? This is a larger health question to ask."

Dr Anant Bhan to The Quint

Similar to Pandey, Amna Khatoon, 43 from Lucknow, who also joined the programme in 2006.

“We haven't paid a fixed or permanent salary ever. Nor have we been given the status of a health worker. We've not been told what our future would look like, what we will get. Our BIMA has not been done. Our job duty is 24x7, and there is no proper salary.”

Amna Khatoon, ASHA to The Quint

Khatoon stated, “We need the recognition of a health worker so that we don't keep facing hurdles and are able to easily access the hospitals and arrange for our stays when we're working late at night. There is no safety or provision for us at night. No retirement time or plan, no pension or security.”

ASHAs stated that part of the reason they have not been getting their payments timely is because they have been informed that "zila se paisa nahi aata hain." (no money from the district). But no reasonable or proper explanation has been given so far.

The Digital Imposition

Most ASHA women stated that one of the biggest complaints is that even the operators have been removed and the sole responsibility of filing, registering and updating data online have been imposed on them.

A few kilometers away from Barola, inside a lane in a busy market lives Rajkumari, 40, who spoke about how they don’t receive any money for vasectomies they got done of others. To show her entry, she talked about the mobile phone they received from the government two years ago.

Rajkumari showed E-Kavach App wherein ASHA workers are required to make an ABHA ID, fill in every day’s work, right from surveys to programmes and golden cards for the Ayushman Bharat scheme.

Rajkumari told The Quint, “I inform at home that I am going to work but then I return with no money on most days. We submit a report on 21st of every month, but the money for our tasks take 3-4 months to arrive."

Indu Bala, Union's President, Lucknow joined ASHA in 2009 when she was 22 years old.

She noted that girls as young as those who have passed class 8 and 10 are hired as ASHAs. "How will they understand when the language chosen is English? How would they operate everything online? Let alone make them dependent on it?" asked the workers.

Bala stated, “ASHA 'behens' have become so tired that now they would rather spend Rs 1,000-2,000 out of their pocket and go to a cyber cafe and get the details registered and uploaded with their help.”

This study 'Assessment of Workload of ASHAs' from 2022 observed that even though as per ASHA operational guidelines, the standard working hours is considered 16 hours, most of them work over 30 hours per week.

Besides, even after becoming an ASHA didi or bahu, they faced a lot of prejudices from their own families and locals in their area.

“In Anouni village, Ghazipur, some relatives of mine used to say, ‘Where are you going to loiter and have fun? Where do you stay at nights? How many thousands do you even earn?" recalled Pandey.

Bala also stated, “I used to hear comments like, ‘There she's leaving with her jhola,’ ‘She's that one's Bahu and going there.’ After some time, people started realising the work I do and why I do it. Now even if they have to take a tablet or get a tika done, they consult me.”

Dr Bhan concluded that the other solutions could be to adjust their incentives for the cost of living, give them social support beyond insurance, specify their role and restrict to that work.

Meanwhile, all ASHA women continue to take help from their sisters, daughters or sons at home to fill the surveys on the mobile phones.

For them, a bittersweet solidarity has come from ASHAs themselves as in Khatoon’s case whose income is dependent on her work as an ASHA.

“My 'saathis,' ASHA sisters have helped me even financially sometimes, at times even the supervisors have also given me money to run my household when I had no income,” said Khatoon.

(The Quint has also reached out to officials at National Health Mission, including the Mission's Director in Uttar Pradesh. Their response will be added once received).