No Asha for ASHAs

A first-hand account of Laija M’s daily struggle as one of Kerala’s 26,125 underpaid health activists reveals the human story behind their protest, exposing the stark paradox within the state’s celebrated health system.

Laija M wakes up at 4am every day, prepares food for her husband and two children, and completes household chores before rushing out of her tin-roofed house in Purapuzha village in Idukki. Her day is spent providing essential health services to the underprivileged, including senior citizens, women, and children.

As an Accredited Social Health Activist (Asha), she trudges long distances through hilly terrains to meet people, collect samples, conduct health surveys, and complete a myriad of tasks before returning home late at night. Despite her tireless efforts, the Rs 7,000 monthly honorarium she earns is barely enough to cover her family’s expenses in a state where vegetables, fish, and meat are pricier than in other parts of the country.

Laija is one of 26,125 Asha workers in Kerala under the National Health Mission of the Union ministry of health and family welfare. These workers serve as a crucial link between the community and the public health system. However, they are now on a warpath, protesting against both the state and central govts, demanding an increase in their honorarium and timely payment of the meagre fees they receive for fieldwork. There is one Asha worker for every 1,000 people.

During the Covid-19 pandemic, Laija and her colleagues were celebrated as heroes for their selfless service, often risking their lives and exposing their families to infection. Today, however, they feel ignored as their protest enters its 40th day on the pavement outside the Secretariat in Thiruvananthapuram. Braving rain, harsh sunlight, and cold nights, they survive on donated rice gruel and change clothes under tarpaulin sheets.

“I joined as an Asha worker in 2007, thinking it was a part-time job requiring only two to three hours of work daily,” she recalls. “Back then, it was just one of many odd jobs I did to support my daily-wage husband. But over the years, the workload has increased significantly. Now, I work from 9am to 6pm and often have to rush out again if there’s an emergency call at night. I skip lunch most days to finish my work in one go.”

The Asha workers at the village level have around 10 categories of work in addition to being part of the subcommittees, health meetings and others. These include antenatal care, monitoring women’s health, providing medicines to seniors, organizing nutrition and yoga classes, conducting sanitation committee meetings, and maintaining records. They also use the Shaili App to conduct surveys on lifestyle diseases, tuberculosis, leprosy, and cancer.

There is strict monitoring at multiple levels—village, sub-centre, primary health centre, block primary health centre, district and state as per the National Health Mission guidelines. Failure to complete any duty means forfeiting the honorarium, which is often delayed by two to three months. Although the state govt has relaxed some conditions after the protests began, the challenges remain immense.

“If I fail to complete even one of my assigned duties as per the set targets, I won’t receive my honorarium, which, in any case, is paid only once every two or three months,” said Laija. (The state govt has removed some of these conditions after the workers started their protest).

Laija’s work also involves unexpected expenses. She must download the Shaili App on her smartphone, which often struggles to handle the load, requiring repairs or replacements. Travel costs add to her burden, as buses are infrequent in rural areas, and autorickshaws charge at least Rs 100-Rs 200 for return trips. “I have to ask my husband or relatives to drop me at the health centre, which means additional petrol expenses,” she says.

Much of the work Laija and her colleagues do is often taken for granted. For example, she has to search for male volunteers to accompany her while monitoring leprosy patients, ensure the centre is kept clean, and even arrange funds for balloons and decorations for the pulse polio vaccination programme.

In addition, workers face some unusual requirements. Laija must maintain a diary recording committee meetings and health monitoring details, which she must carry at all times. “We never know when we’ll get a call asking for details,” she explains.
“On pulse polio day, we’re not allowed to leave home, even for emergencies like deaths in the family,” she says. “Collecting sputum and blood samples is tough because people often don’t cooperate,” says her colleague, Suryalatha R from Thrikkadavur in Kollam.

The additional fees Asha workers receive for specific tasks—Rs 225 for pulse polio vaccinations and Rs 2 per house for dengue prevention checks—are not only meagre but also frequently delayed. “I don’t know when some of the money will arrive. Until then, I have to spend from my pocket,” says Suryalatha.

Many workers gathered at the protest feel deeply hurt by the govt’s disregard for their daily struggles. “We were heroes during Covid-19. Now, the govt acts like it doesn’t need us,” says Shaila Shibi from Idukki, who joined the protest with her carpenter husband. “It’s painful because many of us continued emergency work, like pregnancy care, even after the protest began. Now, we’ve stopped all work.”

The state govt has cited financial difficulties and the Union govt’s withholding of funds as reasons for not meeting the workers’ demands.

Amidst a war of words between the state and central govts, and opposition parties attempting to capitalize on the protests, the Asha workers remain cautious. “We don’t want political parties using our protest to blame others,” says Mini, a leader of the Asha Workers Association.

“Such allegations have caused us immense hardships.”
Nevertheless, workers like Laija are determined to continue their fight. “I will fight till my last breath. I don’t care what happens to me. This is a matter of livelihood,” she declares.