Authors: Pranab Chatterjee, Anita Shet As the second wave of COVID-19 coursed through India the world is waking up to the reality…
A transformative change in India’s health system came with the introduction of Accredited Social Health Activists (ASHA, meaning hope in Hindi) in 2005 in the National Rural Health Mission (NRHM). ASHA workers are women aged 25-45 years, selected from among the residents of a village, who act as the first point of contact between the community and the health system. They receive training and are responsible for referral and escort services for reproductive and child health, promoting universal immunization, nutrition and health education of the communities, and mobilizing communities for health planning, among other roles.  In effect, ASHA workers have become the point of convergence for the implementation of public health programs in India.
The COVID-19 pandemic disrupted health services throughout the world. With its early and stringent lockdown, India was no exception. Reproductive, maternal, neonatal, child and adolescent health (RMNCHA) services were among the those that were affected by the lockdown and subsequent restrictions on access and delivery of healthcare services.
During this time, India’s almost million-strong force of ASHA workers kept the health system running even as other modes of health services became physically and financially inaccessible. ASHA workers not only performed their usual mandate but also undertook additional responsibilities including surveillance, contact tracing, awareness generation, and referrals for COVID-19 diagnostics and treatment. However, at the same time, we also saw large scale protests by the ASHA workers, demanding access to adequate personal protective equipment (PPE) and protection from resistance, often violent, from communities living under the apprehension of COVID-19. This was compounded by delays in receiving their pay, which was often inadequate and unreliable due to its incentive-based nature. 
ASHA workers form the backbone of India’s RMNCHA services. They have contributed to marked improvements in indicators like infant and maternal mortality and total fertility rate. As these gains risk becoming stagnant or even reverse in the wake of COVID-19, strengthening the health system from the ground by empowering ASHA workers is imperative.  Recognizing the quantum and nature of their work and providing adequate remuneration and social security is the first step in this direction.
The incentive-based remuneration for ASHA workers was introduced as their work was meant to be voluntary and part-time. However, ASHA workers remain policymakers’ go-to resource for any new community health intervention and thus their roster of duties has expanded manifold from the originally intended role. As of March 2020, they were responsible for covering over 60 interventions, excluding those related to COVID-19.  This has become a full-time role for most workers. Thus, the nature of their incentivization also needs to evolve with the evolving reality.
The Economic Survey of India 2020-22 recognizes the contributions of ASHA workers as –
‘ASHAs played a key role in the country’s response for prevention and management of the COVID-19. During the pandemic, in addition to performing tasks related to COVID-19, they also continued to support community members for accessing essential health services such as anti-natal care, immunization, safe delivery and treatment adherence for chronic illnesses.’ 
It, however, limits the discussion on their remuneration to an increase to INR 2,000 per month and coverage under Prime Minister’s Garib Kalyan Package insurance scheme, announced during the pandemic. Whilst these steps are welcome, ASHA workers are not entitled to a minimum wage, as seen in the Draft Code on Wages (Central) Rules, 2020, which excludes them. The same holds true for the Code on Social Security, 2020. [8,9
It is often argued that the performance-based incentives are the very reason why ASHA workers perform well. By making each service delivered to each individual linked to a cash incentive, ASHA workers are nudged to deliver a range of services to the maximum number of people. However, such a system need not be exclusive from ensuring a minimum guaranteed pay to the ASHA workers, over which such performance-linked incentives can be retained.
Other arguments in favor of the status quo resonate the cost of such incentivization and the resulting change in the center-state contributions to the scheme as the workers would be entitled to central government pensions. The National Health Policy (NHP) 2017 envisions increasing health expenditure by the central government as a percentage of GDP to 2.5% in 2025. This remained close to 1.6% in 2020. Sufficient fiscal space can be created if the government were to achieve the target of the NHP 2017. In addition, the responsibility of providing for social security benefits to the workers can be worked out between the center and the states, as is being done for many other schemes.
ASHA workers’ contributions to maternal and child health have been highlighted during the COVID-19 pandemic. They facilitate essential healthcare interventions, often at great personal physical and financial cost, with a diligent sense of service to society. Intended to be voluntary part-time workers, they have come to play an indispensable role in improving maternal and child health outcomes. It is time the society acknowledged their contributions and paid them their due.
Ishita Jain is a health policy researcher. This post was developed as part of the course titled “The COVID-19 Response in India: Impact on Women and Children’s Health and Wellbeing”, which was delivered by the Johns Hopkins Maternal and Child Health Center, India, launched by the International Vaccine Access Center at the Johns Hopkins Bloomberg School of Public Health.
The author declares no competing interests
- Ministry of Health and Family Welfare, Government of India. National Health Mission. About Accredited Social Health Activist. https://nhm.gov.in/index1.php?lang=1&level=1&sublinkid=150&lid=226
- World Health Organization. Pulse survey on continuity of essential health services during the COVID-19 pandemic: interim report, 27 August 2020. 2020. https://www.who.int/publications-detail-redirect/WHO-2019-nCoV-EHS_continuity-survey-2020.
- Down to Earth. Recognise ASHA workers’ COVID-19 work, ensure their well-being: Report. 2020. https://www.downtoearth.org.in/news/health/recognise-asha-workers-covid-19-work-ensure-their-well-being-report-73446
- B Mane Abhay, V Khandekar Sanjay. Strengthening Primary Health Care Through Asha Workers: A Novel Approach in India. Primary Health Care. 2014; 4. https://www.iomcworld.org/open-access/strengthening-primary-health-care-through-asha-workers-a-novel-approach-in-india-2167-1079.1000149.pdf
- Manchanda NK. Maternity and child care amidst COVID-19 Pandemic: A forgotten agenda. 2020; 1:2. http://www.jogh.org/documents/issue202002/jogh-10-020334.pdf
- Press Information Bureau. ASHA Workers. 2020. https://pib.gov.in/newsite/PrintRelease.aspx?relid=200175
- Ministry of Finance, Government of India. Chapter 10 Social Infrastructure, Employment and Human Development in Economic Survey 2020-21. 2021. https://www.indiabudget.gov.in/economicsurvey/doc/vol2chapter/echap10_vol2.pdf
- Ministry of Labour and Employment, Government of India. Draft Code on Wages (Central) Rules, 2020. https://labour.gov.in/sites/default/files/gazette%20notification.pdf
- Ministry of Labour and Employment, Government of India. The Code on Social Security, 2020. https://labour.gov.in/sites/default/files/SS_Code_Gazette.pdf
- Ministry of Health and Family Welfare, Government of India. National Health Policy 2017. https://www.nhp.gov.in/nhpfiles/national_health_policy_2017.pdf