The Backbone of Kerala's Healthcare: Understanding the Journey and Struggles of ASHA Workers.

 Kerala, often celebrated for its exemplary public healthcare system, relies significantly on a dedicated group of individuals who often remain behind the scenes: the Accredited Social Health Activists (ASHAs). These frontline healthcare providers are the crucial first point of contact for many, diligently working to raise health awareness, deliver essential services like disease screening and immunizations, and provide vital support for maternal and child health, frequently under demanding conditions and for modest compensation. The recent surge of protests in Kerala brings to the forefront the systemic challenges these essential workers face, highlighting their persistent demands for fair remuneration and improved working conditions. The juxtaposition of Kerala's high healthcare standards with the struggles experienced by its frontline workers suggests potential areas within the state's healthcare model that warrant closer examination and possible enhancement. Furthermore, the fact that these protests occur despite international recognition of ASHA workers' invaluable contributions to global health  indicates a possible disparity between global appreciation and the level of support and valuation these workers receive at the national and state levels.

The Formation of ASHA Workers in Kerala

The establishment of the ASHA program in India can be traced back to 2005, when it was launched under the National Rural Health Mission (NRHM) by the Ministry of Health and Family Welfare (MoHFW). The overarching goal of the NRHM was to improve healthcare access, promote healthier practices, and enhance awareness regarding government health services, particularly in rural and underserved regions across the country. The central vision was to have an "ASHA in every village," creating a vital link between marginalized communities and the formal healthcare system. This national initiative in 2005, aimed at addressing the rural health crisis, signifies a recognition at the central government level of the critical need for community-based healthcare workers to effectively bridge the gaps within the existing healthcare infrastructure.

Kerala, despite its already well-established public health system, adopted the ASHA program relatively later compared to many other states in India, with the program becoming operational around 2007. By July 2009, significant progress had been made, with over 30,000 ASHAs selected and nearly 28,000 deployed in the field following their initial induction training. The somewhat delayed implementation of the ASHA program in Kerala, a state already known for its robust public health system, prompts questions about the initial perceived necessity of the program or potential challenges in integrating it within the existing healthcare framework. It is possible that the state government undertook a careful assessment of how the ASHA program could best complement its already strong healthcare delivery mechanisms.

The initial vision for ASHA workers in Kerala, consistent with the national framework, was to establish them as a crucial link between the community and healthcare services, ensuring that primary healthcare reached the rural poor effectively. These women, primarily selected from the communities they served, were intended to function as health educators and promoters, building trust and strong relationships with the local population. The emphasis on recruiting women from the local community underscores the program's understanding of the importance of leveraging local knowledge and established social networks to facilitate effective healthcare delivery at the grassroots level. This selection criterion suggests a recognition that community trust and cultural sensitivity are vital components of successful healthcare outreach.

Roles and Responsibilities: The Expanding Duties of ASHAs

The core responsibilities initially assigned to ASHA workers were diverse, encompassing motivating women to give birth in hospitals, ensuring children received immunizations, promoting family planning methods, providing first aid for basic illnesses and injuries, maintaining demographic records, and working to improve village sanitation. They were also tasked with supporting pregnant women and new mothers by providing essential prenatal and postnatal care.1 Furthermore, ASHAs were envisioned as playing a key role in raising awareness about health issues and their social determinants, as well as mobilizing their communities to participate in local health planning initiatives. They also served as depot holders for essential medical supplies such as Oral Rehydration Salts (ORS), Iron Folic Acid (IFA) tablets, and contraceptives. This initial set of responsibilities was broad, covering a wide range of basic healthcare and health promotion activities, indicating the multifaceted role intended for ASHAs from the program's inception.

Over time, particularly in a state like Kerala known for its proactive approach to public health, the roles and responsibilities of ASHA workers have expanded significantly. They became increasingly involved in the prevention and control of communicable diseases, the identification and management of non-communicable diseases (NCDs), the provision of palliative care for chronically ill patients, and participation in community-based mental health programs. During public health emergencies, such as the COVID-19 pandemic, ASHA workers in Kerala were at the forefront, playing a critical role in disseminating accurate information, coordinating vaccination efforts within their communities, and ensuring adherence to essential preventive measures. Their dedication extended to supporting community members in quarantine and isolation, even assisting with the delivery of groceries and essential supplies. This expansion of roles, especially during the pandemic, demonstrates the increasing reliance on ASHA workers as frontline responders in various health crises, often taking on duties that extended beyond their original mandate. This evolution suggests a pattern of task-shifting, where ASHA workers are entrusted with more responsibilities due to their established presence and accessibility within communities.

In addition to direct healthcare and health promotion activities, ASHA workers in Kerala play a vital role in data collection and reporting, contributing significantly to the state's public health database by gathering information on diseases and mortality. Since 2018, there has been a significant push for digital infrastructure in healthcare, which has substantially increased the workload of ASHA workers related to data entry. They are now required to use various digital applications, such as Shaili and Shaili 2.0, to input detailed information about individuals in their assigned localities, including demographics, medical history, and lifestyle factors. This increasing emphasis on digital data collection represents a notable shift in the nature of ASHA workers' responsibilities, potentially moving them from a primary focus on direct community care to more administrative and data-centric tasks. While digitalization holds the promise of improved data management and healthcare planning, it also introduces a considerable burden on ASHA workers, who may face challenges related to digital literacy, access to reliable devices, and the time required for these tasks.

Overtime Issues: The Growing Burden on ASHA Workers

The classification of ASHA workers as "voluntary health workers" stands in stark contrast to the reality of their often full-time engagement and the continuously expanding scope of their responsibilities. Many ASHA workers in Kerala report working seven days a week for extended durations, sometimes up to 10 to 12 hours each day. They are frequently expected to be available on call, ready to respond to community health needs at any time. This fundamental contradiction between their "volunteer" status and the actual demands of their work is a central issue fueling their persistent calls for formal recognition as workers, entitled to the corresponding labor rights and benefits. This misclassification potentially leads to the undervaluation of their labor and the denial of fair employment practices.

The increasing workload, particularly with the added responsibilities of data entry through various digital platforms, has significantly extended the working hours of ASHA workers. They often find themselves needing to complete data entry and reporting tasks after their regular field work is done, which encroaches upon their personal time and rest. This digital workload appears to be a major contributing factor to the overtime issues faced by ASHA workers, as it adds a substantial new layer of responsibility on top of their existing community health duties. This suggests that while technological advancements are intended to enhance efficiency within the healthcare system, they may inadvertently be increasing the burden on frontline workers without providing adequate support, training, or compensation for the additional time and effort required.

The current payment system for ASHA workers in Kerala, which primarily consists of a monthly honorarium and performance-linked incentives, does not adequately compensate them for their increasing workload and the extended hours they dedicate to their duties. While incentives are provided for specific tasks and achievements in health programs, they often do not encompass the full scope of their responsibilities or the actual time spent on their work. This reliance on honorariums and selective incentives creates financial instability for ASHA workers and fails to fully recognize the growing demands placed upon them, effectively undervaluing their essential contributions to the healthcare system. This compensation structure does not reflect the reality of their workload and the critical nature of their role in delivering primary healthcare services to communities.

Present Issues and the Ongoing Protests

Currently, ASHA workers in Kerala are actively engaged in widespread protests, primarily demanding a significant increase in their monthly honorarium, with figures such as Rs 21,000 being frequently cited. Another crucial demand is the provision of comprehensive retirement benefits, including a pension and a one-time retirement package, often specified as Rs 5 lakh. Formal recognition as "workers" under existing labor laws is also a key demand, as this would grant them access to fundamental rights and protections afforded to other employees. Additionally, they are protesting for improved overall working conditions, the timely and regular payment of their wages, and the rollback of certain digital health initiatives that have significantly increased their workload without adequate support or compensation. The consistency of these demands across various reports and statements from ASHA workers highlights the fundamental and long-standing nature of their grievances in Kerala.

The ASHA workers in Kerala have been conducting prolonged protests, including continuous sit-in demonstrations and hunger strikes, often held outside the state secretariat in Thiruvananthapuram.13 These protests have garnered significant support from various segments of society, including artists, intellectuals, and other labor organizations who recognize the validity of their demands. In a powerful symbolic act of protest, some ASHA workers have even shaved their heads to express their deep distress and disillusionment with the government's response. Furthermore, a statewide protest march, spanning 45 days from Kasaragod to Thiruvananthapuram, has been organized, indicating a significant escalation of their ongoing agitation. The intensity and duration of these protests, including the symbolic act of cutting hair, underscore the profound frustration and the urgent need for their demands to be addressed.

The Kerala government has engaged in multiple rounds of discussions with representatives of the ASHA workers; however, these talks have not yet resulted in any concrete resolution to the issues raised. The government has often cited financial constraints as a limiting factor in meeting the workers' demands and has, at times, emphasized the central government's role in funding the ASHA program. Accusations of political maneuvering and blame-shifting between the state and central governments have also surfaced concerning the responsibility for ensuring the welfare of ASHA workers. While the government has proposed the formation of committees to further examine the ASHA workers' demands, some of the leading ASHA organizations have rejected these proposals, insisting on more immediate and decisive action to address their long-pending grievances. This lack of a resolution, despite numerous discussions and the ongoing blame game, points to a complex interplay of political and financial factors that are unfortunately prolonging the struggle of the ASHA workers in Kerala.

Compensation and Working Conditions: A Critical Analysis

Currently, ASHA workers in Kerala receive a monthly honorarium from the state government, which is reported to be Rs 7,000. In addition to this, they may also be eligible for supplementary performance-based incentives linked to various national health programs. Nationally, the central government provides a fixed monthly incentive for routine and recurring activities, which was revised to Rs 2,000 per month in 2018-19 from the previous Rs 1,000. Further incentives are available for participation in specific national health initiatives. However, there have been consistent reports that the disbursement of the state-level honorarium is often subject to delays and that deductions are sometimes made for failure to meet specific criteria or for missing assigned tasks. This dual system of honorariums and incentives creates an income that is often unpredictable and insufficient for ASHA workers to rely on as a stable primary source of livelihood.

A comparison of the current honorarium received by ASHA workers in Kerala with the state's minimum wage reveals a significant disparity. The monthly honorarium of Rs 7,000 translates to approximately Rs 233 per day, which is considerably lower than the prescribed minimum daily wage of Rs 700 for workers in the unorganized sector in Kerala. Furthermore, when compared to other states in India, some, such as Sikkim, Andhra Pradesh, and Karnataka, offer higher monthly honorariums to their ASHA workers. Notably, the state of Andhra Pradesh also provides retirement benefits to its ASHA workers, including a substantial gratuity upon completion of a certain number of years of service. This comparison highlights the potential for the Kerala government to improve the financial well-being of its ASHA workers by considering an increase in their honorarium and the provision of retirement benefits, aligning with practices in other states.

Beyond the issue of inadequate compensation, ASHA workers in Kerala often face challenging working conditions. Reports indicate a lack of essential resources such as proper uniforms, umbrellas to shield them from harsh weather, or adequate protective gear, despite the fact that their work often requires them to traverse difficult terrains and work in varied climatic conditions. Many ASHA workers also encounter transportation difficulties in reaching the communities they serve and often incur out-of-pocket expenses for work-related travel, which further strains their already limited financial resources. Additionally, there have been accounts of ASHA workers feeling a lack of recognition for their crucial contributions, experiencing inadequate support from the formal health system, and being assigned duties that fall outside their primary healthcare responsibilities, such as assisting with non-health-related government events. The increasing demands related to digital data collection also add to the overall stress and can exacerbate the existing challenges faced by these frontline workers. The combination of low pay and these difficult working conditions can contribute to burnout, decreased morale, and potentially have a negative impact on the quality of the essential healthcare services that ASHA workers provide to their communities.

Conclusion

ASHA workers form an indispensable pillar of Kerala's primary healthcare system, playing a critical role in extending healthcare access to vulnerable populations and ensuring the successful implementation of various essential health programs. To ensure their well-being and the continued strength of Kerala's healthcare system, it is imperative that the government addresses their legitimate and long-standing demands for fair compensation, improved working conditions, and formal recognition of their crucial role. Neglecting the concerns of these frontline workers could lead to increased burnout, higher attrition rates, and a potential decline in the quality and effectiveness of primary healthcare services across the state. A just and equitable resolution that genuinely acknowledges the invaluable contributions of ASHA workers to society is essential for upholding the principles of accessible and quality healthcare in Kerala.