Ayushman Bharat & Poll Promises: Why ASHA Women Are in a 'Catch-22' Situation

Why are ASHA women not celebrating their inclusion in one of the government's flagship schemes?

This election season, ASHA women want solutions.

Following the fanfare over being inducted into the Ayushman Bharat scheme earlier this year, Kaushalya Rawat, 44, an ASHA worker from Mohanlalganj in Uttar Pradesh's Lucknow district, told The Quint:

"Who are these ASHA women the government is saying are happy with being included in the Ayushman Bharat scheme? I haven't seen any ASHA didi praise it."

Rawat is the district vice president of their union, the ASHA Bahu Kalyan Samiti, and her sentiment is shared by many ASHAs.

"They are fooling and misleading the public," Rawat added.

During her interim budget speech this year, Union Finance Minister Nirmala Sitharaman said, "Healthcare coverage under the Ayushman Bharat scheme will be extended to all ASHA workers, Anganwadi workers, and helpers."

Shortly after, the Bharatiya Janata Party's (BJP's) official X account posted these images to mark their inclusion into the scheme.

This means that almost two decades after the ASHA programme was launched, the Narendra Modi-led government will provide ASHA workers with "cashless and inpatient medical services up to Rs 5 lakh per family per year." This is for households below the poverty line (BPL) identified through the Socio-Economic Caste Census 2011.

But why are ASHA women, who act as the backbone of rural India's healthcare system, not celebrating their inclusion in one of the government's flagship schemes?

This is the second part of our two-part series on ASHA women this election season. In the first part, we explored a day in their lives, the endless labour, and the various difficulties they face in navigating the digital burden. In this piece, ASHA women elaborate on their concerns about their Ayushman Bharat inclusion – and the complexities of even raising some of their demands.

A Blessing or an Added Burden?

Sarita Yadav, 40, an ASHA from Lucknow, noted that their inclusion in the scheme, which came close to the 2024 Lok Sabha elections, is not only "too little, too late", but also fails to address their long-drawn demands – like recognising them as health workers with a fixed salary and social security.

"All of us are just exhausted and fed up with the endless work and no money," Yadav remarked.

Even though they have been included in the scheme now, ASHA workers have been responsible for making Ayushman cards (golden cards) for the last two years.

As they explain, making these cards are an added burden for them over and above conducting community surveys; bringing in people for vaccinations and making a record of it; accompanying pregnant women to hospitals for medical checkups, delivery, and postnatal care; and attending programmes related to filaria, polio, and other diseases.

"Instead of including us in Ayushman Bharat, they should give us a fixed salary even if it's Rs 10,000-15,000 per month. Give us the status of state or national health worker – and clear all our dues for the tasks we do," said Yadav.

She noted that ASHAs are given a target of making golden cards for 1,000-2,000 households a month. For each card, they get only Rs 3-5.

Moreover, Amna Khatoon, 43, an ASHA worker from Lucknow, explained that ASHAs who are eligible to make golden cards have to either have a BPL card, their name in 2011 census records, or have six or more members in the family who are below the poverty line.

To add to the workload is the challenge of technology – and the language barrier.

"There used to be computer operators by the government who took care of it (recording the data), but they shifted them from the field to hospitals, and put the load of making Ayushman cards on us."

Indu Bala, ASHA

Bala further added that using the mobile is not easy for all ASHAs. "It's on mobile and it's English to English. How will ASHAs, who have studied only till class 5-6, do all this? They're struggling with it and it's affecting their work."

Yadav stated that so far in the past year or so, she has only been able to make 10-20 golden cards as the mobile phone given by the government hardly works. It glitches and hangs very often, she added.

Damned If They Do, Damned If They Don't

From mid-February till the end of March, ASHAs observed the 'Kalambandh' dharna in Uttar Pradesh – the most populous and politically significant state in the country.

Reverberating with the slogans of "Humaari Maange Puri Karo, Hum Ko Permanent Karo!", ASHAs protested ahead of the elections in many primary and community health centres in the state, including Lucknow, Malihabad, Varanasi, Unnao, Raebareli, and Kanpur, among others.

ASHAs stated that during the 2019 general elections, they were promised a salary hike. Now, they all share the same sentiment: "Where there is no salary, what will you give a hike on?"

The state-wide protests were met with resistance by state authorities, but they stood their ground. However, the prolonged protests – with no results – put them in a 'Catch-22' situation.

Indu Bala, vice president of the union in Lucknow, much like the others, stated that if they continue to protest, they will lose their daily earning for the tasks assigned to them. This year alone, she has only been able to make 50-60 golden cards with a lot of difficulty.

"For every day that we protest, we lose our earnings. Paer par kulhaadi maarne jaesa hai. We are willing to fight for our rights. ASHAs are speaking out against Ayushman Bharat, but they don't want to say too much to upset the authorities either," Bala told The Quint.

Meanwhile, Dr Anant Bhan, a researcher in health policy and global health, stated that credit where it's due, Ayushman Bharat will prove beneficial for ASHAs in terms of getting access to a service they didn't have before. However, he added:

"The more important questions the system needs to ask are: What do the ASHAs want? How much more can we expect from them? How much can we scale down on our expectations? Does an ASHA worker always want to work as one?"

Speaking about their demands, Rawat stated that the workers demand a fixed salary and until then, at least their incentives should be increased to Rs 18,000 for ASHA workers (didis or bahus) and to Rs 24,000 for ASHA supervisors (sanghinis). The latter work for a much larger population ranging from 18,000 to 24,000 people.

"Working day and night, all the work has been imposed on ASHA bahus. Is the government blindfolded? How can they not see?"

'We Will Resume This Dharna After Elections'

In Lucknow's Eco Garden, around 6,000-7,000 ASHAs had staged protests in mid-February to raise their demands.

However, ASHA didis alleged that the gates were closed, and the police misbehaved with them. Later, the head of their union, Seema Singh, met with the police, but she was left disappointed.

"If we don't get the help we want, then we will continue this dharna. As of now, we haven't gotten any help. We're still waiting just like we have been since years," noted Singh.

"If an ASHA worker is taking care of so much, right from your programmes to surveys and vaccinations on ground, then why can't they be given a uniform or fixed salary? Why can't they be called a karamchari?"

Seema Singh, Union Head

ASHAs across the state had submitted their demand letters to the authorities – a copy of which is with The Quint. Their demands included:

• Recognise them as permanent government health workers.

• To avail timely benefits under the PM Jan Arogya Yojana, include ASHA workers and supervisors as permanent health workers.

• Instead of giving them money in instalments, provide them with a fixed honorarium.

• Recognition given by WHO during the tasks performed in COVID-19 pandemic was not enough; they want a definite pay in their future.

• To be informed of support and incentive money and various other types of vouchers when available as they are "humiliated when they ask officials."

When Bala met Dr Pinky Jowel, Mission Director of National Health Mission in end of March in Uttar Pradesh, she alleged that she was told that she cannot help with the additional work of Ayushman Bharat "as they are orders from the Centre." However, in exchange of them temporarily holding off their protests, Dr Jowel had assured them that their demands will be met this election season.

ASHAs have also submitted their demand letter to SDM, Lucknow, Hanuman Prasad, and Tehsildar Priya Vanda Misra of Mohanlalganj.

"The SDM has told us that he will convey the matter to the health minister and has assured us that something will be done," Rawat told The Quint.

Now, ASHA workers seem to have made up their mind. They are determined to resume their protests if the assurances fail.

"When we have to vote, we will also let our answers know by the button we press during polling. They will know what we can do then and hear our voice for a change," exclaimed Rawat.

But in light of no response from the authorities yet, ASHA workers said:

"We were given assurance that before elections begin, some of our demands would be met but nothing has happened yet. ASHAs in UP have not received their payments in two months and we're told it's because of the elections and will be sorted out after. But we're planning to protest right after the elections even if it puts us at a disadvantage, where will we go? What do we do?"

(The Quint has also reached out to the National Health Mission in UP. Their response will be added once received).