(This was first published on 17 February 2021. It has been republished from The Quint's archives after India's ASHA workers were honoured with the Global Health Leaders Award-2022 by the WHO.)
The 2021 Budget was celebrated as a victory for rural healthcare schemes that have received increased allocations. However, Accredited Social Health Activists (ASHA) and anganwadi workers (AWW), who have been protesting across Indian states for the last few months, stand to gain little from these increments. These community health workers have been point-persons for rural communities to access key health services and benefits. ASHAs and AWWs have been going to extreme lengths to ensure that the households they serve are able to access State entitlements, raising the question of why their entitlements remain unrecognised.
ASHAs and AWWs are part of different government programmes but work closely together to improve community health and nutrition.
Both are especially focused on maternal and child health, with AWWs trained in immunisations as well as education and nutrition for young children. ASHAs go door-to-door to offer a variety of services, which include nutrition counselling; family planning; and monitoring key diseases like TB and malaria. Each worker covers an average of 1000 households, with many having to cover upto 2000.
No Access to Fixed Minimum Wages
The pandemic mounted severe pressure on ASHAs and AWWs. With little training and immense risk, they went to households to spread awareness on COVID-19 as well as carry out tasks like contract tracing. Alongside these new pandemic responsibilities, both ASHAs and AWWs were still involved in providing essential services of nutrition and health, mostly without any protective equipment. While pre-pandemic ASHAs and AWWs provided supplementary nutrition to communities in anganwadi centres, during the pandemic they directly delivered take-home rations to households, when food security was severely compromised for many.
A few months into the pandemic, ASHAs and AWWs across Indian states staged protests when they did not receive months worth of wages since the lockdown.
Both are paid a monthly ‘honorarium’ ranging between Rs 2000 to 4000, depending on state government policies. Legally recognised as part-time volunteers who work an average of 2-3 hours a day, they do not have access fixed minimum wages. Over the years frontline workers have received various promises of wages increases, but many have never received them.
Will Increased Investment in Healthcare Translate into Benefits for ASHAs and AWWs?
The question remains whether the increased allocations to healthcare in the Budget 2021-22 augurs well for ASHAs and AWWs. AWWs are covered under the Integrated Child Development Services (ICDS) Scheme offered by the Ministry of Women and Child Development. The highest allocation within the ministry, of Rs 20,105 crore, has been allotted to Mission POSHAN 2.0 and Saksham Anganwadi. While Mission POSHAN 2.0 clubs the ICDS with other existing nutrition schemes, the newly launched Saksham Anganwadi will work towards the upgrading of existing anganwadi centres. Similarly, the National Health Mission programme have received an increased allocation of Rs. 3,175 crore, most of which is focused on the National Rural Health Mission which covers ASHAs. This is a 4.4 percent increase for the mission since the previous budget.
The increased investment in healthcare promised by the Finance Minister is unlikely to translate into benefits for ASHAs and AWWs. For instance, the allocation of 20,105 crore to combined schemes is minimal in comparison to the budget of 2020-2021 when 20,532 crore was allotted just for anganwadi services.
Most significantly, the budget presented an opportunity for the State to bring ASHAs and AWWs on payroll and ensure they are paid minimum wages, acknowledging the crucial role they played during the pandemic. Instead, the Code on Social Security passed in September 2020 excluded ASHAs and AWWs from being eligible for basic social protection and income security on account of being volunteer workers.
Discrimination, Violence & Exploitation: What ASHAs & Anganwadi Female Workers Fight Everyday
Marginal budget increases aside, the fact remains unchanged that the overall rural healthcare system remains dependant on the ‘exploitation’ of ASHAs and AWWs. Protests by ASHAs and AWWs are not a product of the post-pandemic world, but have been repeatedly taken place across India before March 2020. While these workers are officially seen as volunteers, their work often requires them to work 12 hours a day to fulfil their entire range of responsibilities. Many ASHAs and AWWs are dependant on this job to financially support their families, however are unable to claim minimum wages on account of being volunteer workers.
Compounded by the marginalisation they face from the State, is the fact that the all-female workforce of ASHAs and AWWs also face stigma within their own communities.
During the pandemic, 33 percent of ASHA workers surveyed by Oxfam recounted being subjected to some form of discrimination or violence due to the stigma associated with healthcare work during the pandemic. Beyond pandemic circumstances however, ASHAs and AWWs who are largely from marginalised communities often face abuse and ostracism as they go door to door.
Why ASHAs & Anganwadi Workers Deserve to be Prioritised by the Govt
An important development in this situation is how the dissent from ASHAs and AWWs has been received. While these workers have been building strong unions with defined collective voices, protests by ASHAs and AWWs across states have been met with police brutality during protests and filing of FIRs against workers.
With their dissent being criminalised, the space for ASHAs and AWWs to claim their rights is shrinking.
ASHAs and AWWs form a crucial interface between State and communities to access the public health system. However, they possess limited legal rights as volunteers, meagre monetary compensation, and minimal recognition from the communities they are committed to serving. An illusory budget increase serves no purpose. It is only with tangible incentives of secure salaries that the State can empower ASHAs and AWWs. Considering they are willing to risk their lives to work for communities, it is high time government budgets value and support them.
(Ayesha Pattnaik is a research associate in the research wing of Professional Assistance for Development Action (PRADAN). She studied Sociology at the London School of Economics and Ashoka University, and her interests span human rights and citizenship. She tweets at @ayeshapattnaik. This is an opinion piece, and the views expressed are the author’s own. The Quint neither endorses nor is responsible for them.)