‘My Income Hasn’t Changed In Ten Years, And We Have No Savings’: An ASHA Worker’s Story
Whether it is putting off an urgent surgery or making do with 250 gm of fish for her family of four once a month, Lakhya Hira Phukon, like most other poorly-paid ASHA workers, has to balance her domestic budget with extreme care
On a humid summer afternoon, between rains that come and go, I wait for Lakhya Hira Phukon at the Primary Health Centre in the Thana Chariali market area in Tinsukia. The 49-year-old ASHA worker agreed to speak to me about how inflation has impacted her and her family of five and she is running late.
Thirty minutes later, Lakhya, tall, bespectacled and dressed in a violet mekhela sador, walks in and it is clear she is in a huff. She gives me a hurried smile before disappearing into the centre. She is not in a uniform and she says it is not required of them always.
Lakhya has already had a hard day, surveying pregnant women in her ward in Chaliha Nagar and she now has to deal with paperwork – photocopying birth certificates, blood reports and so on – that has to be submitted to the health officials on-site. She draws up a chair for me and carries on with her work even as she answers my questions. “Amar ASHA kormi’r kaam ketiyau hekh nohoi (our work is endless),” she says.
ASHA workers, or Accredited Social Health Activists, are hired as “volunteers” though their work is critical to the delivery of government health programmes aimed at women, children and adolescent girls. Their mandated workload is heavy and they are also pulled into initiatives that go beyond this, such as election work. As we have reported repeatedly, they are underpaid and overworked (here, here and here).
Lakhya, like other ASHA workers in Assam, is paid a monthly honorarium of Rs 3000, among the lowest paid community healthcare workers in the country. On top of this, she is also given incentive-based payments. From the OBC community, she has been working as an ASHA worker since 2010. And she says, with a forlorn smile, that her work has tripled in the last 14 years while her monthly earnings have remained the same.
When I met Lakhya, it was Bohag Bihu, a festival that heralds the beginning of the Assamese New Year. It is a time to spend and celebrate but Lakhya has to be careful with the money. “I will buy clothes for my children but not for myself. I want to give them something for Bihu even if it stretches our finances,” Lakhya says.
Lakhya’s husband runs a small grocery shop near their home and earns Rs 3000-5000 a month, putting their cumulative monthly income at Rs 10,000 a month. They have three children of whom the eldest works for a private company in Guwahati. But their daughter aged 21 and younger son, 20, still need to be supported. Their earnings are simply not enough for the household, says Lakhya. “I have no savings. Ji pau, hetukei khau (whatever I earn is consumed),” she says.
Assam’s inflation rate of 6.08% is higher than the all-India rate of 5.09%, per government data from February 2024. Manipur (10.9%), Odisha (7.5%) and Telangana (6.7%) are the top three states with highest inflation rates. Inflation (the measure of the rate of increase in the prices of goods and services) is calculated using the consumer price index (CPI) and the wholesale price index (WPI). The measure of inflation determines the purchasing power of the consumer.
With rising inflation, household debt is at an all-time high – 40% of the Gross Domestic Product (December 2023). And there has been a 47-year low in the net financial savings – at 5.1% of GDP. These together define the financial distress that households in India are grappling with.
At BehanBox, we are seeking to map the costs and burdens of this distress in real time through ‘Inflation Journals’, a series from across India that began last week.
‘Can’t Afford Train Ticket’
Most ASHA workers earn an average of Rs 5000-Rs 8000 per month, an amount that has stagnated over 10 years, according to several we interviewed. This is way below the state mandated minimum wages for skilled workers who are entitled to a monthly wage of Rs 14,239.
It is hardly surprising that Lakhya is having a hard time balancing her earnings and expenses. Her younger daughter, Diksha, 21, is finishing her undergraduate degree at Tinsukia’s Women’s College. “She wants to pursue an MA,” Lakhya says with pride. Her daughter has always been bright and consistently managed good grades so she is keen to support her even if her finances are tight. “Etiya sinta korisu, suali’k keneke MA porham (I worry I wont be able to fund her Masters,” says Lakhya.
Her other son is currently unemployed and after finishing his 12th exams, took a gap year. “Currently, both my son and Diksha are taking computer classes that cost Rs 500 a month. It is necessary since all work nowadays is done on computers,” says Lakhya.
How does she cope with rising expenses, I ask her. Loans, she replies, taken from friends, relatives and banks. Subsisting on loans to cope with inflation is a recurrent phenomenon, as we reported in the first of our Inflation Journals from Andhra Pradesh, featuring a farmer, Gedda Lakshmi. Lakhya is also part of the ASHA workers’ union and it also serves as an informal support network for workers in a financial crisis.
Twenty years ago, Lakhya took out a Rs 1 lakh loan from her bank to buy her older son a laptop. Still is still repaying it. She was planning to go to Guwahati the next day for an ASHA state committee meeting. “I had to borrow Rs 2000 for the train ticket from fellow ASHA workers,” she says.
Other Asha workers I meet are furious at how undervalued they are. “Boro boro minister ra bole je ‘amrao’ desher jonno voluntary kaaj kori. Tahole, ora kemne lakh taka paye aar amra kichui paina (ministers say that they are doing voluntary work for the nation. And so do we. So why are they earning in lakhs and we in pennies?),” fumes Archana Sen, 44, another ASHA worker sitting beside Lakhya.
Pubali Moran, 48, another ASHA worker, is a single mother and earns between Rs 4000 and Rs 8000. She too struggles to run her household and her income has more or less remained stagnant. To deal with her expenses, most of the time she walks from her house in Chirwapatty Road to the PHC and Civil Hospital, a distance of 1.4 km. And then she starts her daily rounds.
Sometimes the people she surveys offer to pay her for transportation. “Hathot 10 toka’u nathake, ami khujkahi jabo lage (sometimes we don’t even have Rs 10 in our pockets. We just walk then),” she says.
Before 2017, ASHA workers’ earnings in Assam were based on their tasks and they were paid a fixed honorarium of Rs 1000 from the Centre, which was increased to Rs 2000 in 2019. But after several protests, workers here started to be paid Rs 1000 by the state too, Lakhya tells me. Now they earn a total of Rs. 3000 as their fixed honorarium. For the past few years, ASHA workers unions have been demanding that they be paid Rs 21,000 per month and also be absorbed as full-time employees with access to government employee benefits.
‘We Eat Fish Once A Week’
Lakhya’s favourite fish is puthi, a freshwater fish found in the local water bodies. But at Rs 400 a kg it is too expensive for the family. So Lakhya buys only 250 gms of the fish once a week for Rs 100 and the family has it over one meal. They have eggs more often but meat infrequently.
Her son is fond of eating chicken but it is made only once a month as a treat. Sometimes her patients give her Rs 50-Rs 100 and that means an extra helping of fish that day.
Lakhya’s family receives 25 kg of subsidised rice grains at Rs 3 per kg. But everything else is expensive – cereals, pulses, edible oils, milk, fruits, tea leaves, and sugar, for instance. means that this subsided food grain makes little difference to her budget. Reports have suggested that the quality of this rice is extremely poor.
Lakhya says that of the Rs 10,000 the family earns, Rs 6000 is spent on food consumption. The rest is spent on utilities, transportation, and other necessities, leaving zero savings.
I ask her if she has bought herself anything in recent days. She laughs as she tries to jog her memory. “I don’t really buy anything for myself out of leisure. But I do invest in sandals from time to time because they wear out from all my walking,” she says. “This January I had to replace my glasses because I needed new ones. They cost me Rs 1500 but I could not do without that expense.”
Rs 250 For Monthly Travel Expenses
Lakhya wakes up at 5 am everyday, takes her morning cup of black tea and then starts working on the family’s breakfast, followed by lunch and other chores.
She leaves for work at 10 am, only to come home by 5 pm. ASHA workers are assigned 74 tasks which take more than 8 hours to complete. “Amar kamor kuno homoy nai, amak jetiyau call ahe, amak bisonar pora uthi jaboye lagibo (we don’t have a fixed working schedule. Whenever we get a call, no matter the time of day, we have to get out of our beds),” she says.
One of the primary tasks of ASHA workers is identifying and registering new pregnancies in their wards and ensuring that these result in institutional deliveries. For both these tasks, they get paid Rs. 400. However, this is not always the case.
Tinsukia is an urban centre with migrant workers from other districts and states and they come seeking seasonal employment. Many pregnant women that Lakhya identifies and registers during home visits end up delivering in their home states. For this, ASHA workers do not get any payment.
“We still do all the four major check ups for pregnant women who have either registered elsewhere or are way past the three month mark in their pregnancy,” she says. Most of these women are migrant women workers engaged in informal labour like street vending, and construction work. “Manobota’r khati’t beji logai diu, kintu etu kaam kora karone ami eku poisa nepau (we treat these women because of our humanity. But we don’t get paid a single penny for this),” says Lakhya. Another issue is that if these deliveries do not happen in government hospitals, they do not get paid.
In interviews with ASHA workers, we found that the number of such cases ranges from 5 to 6 every month. If the delivery takes place in a private hospital, they are not compensated. This means, they forgo at least Rs 2400 each month from their incomes. Lakhya says her husband taunts her about her work: “Imaan ghuri phuro, ki kaam koro? Ghor solaboye pora nai (you wander about so much for your work, and it doesn’t even pay you enough to run our house).”
Further, workers sometimes do not receive their honorariums and incentives on time, something that BehanBox has documented in its reportage on ASHA workers.
Lakhya gets Rs 250 for all her work travel, including door-to-door visits. But it does not cover the actual travel expenses that are sometimes double the allowance, she says.
Healthcare Expenses
Given that they are not treated as regular employees, ASHA workers have no access to health schemes such as the Central Government Health Scheme (CGHS).
For the past couple of months, Lakhya has had a strange ache in her legs that she occasionally massages mid-conversation. Last year she had gone to the Civil Hospital to get it checked. She took medicines for three months which relieved the pain but it returns often.”I am not sure if I want to visit the doctor again,” says Lakhya. I wonder if this is because it would mean more time and expense spent on tests and treatment.
In India, more than half of healthcare costs are covered through out-of-pocket expenses (OOPE), as reported in a study from 2023. Elevated OOPE levels signal insufficient investment in public health infrastructure, limited access to healthcare facilities, a reliance on private hospitals, and inadequate insurance coverage. Studies in India suggest that this situation annually plunges 63 million Indians into poverty.
Consequently, families are left with minimal resources to allocate towards essentials such as food, basic needs, and additional medical expenses. The outcome of these is often a brutal debt trap, as we report here.
Lakhya’s husband is a recovering alcoholic and suffers from chronic blood pressure, and neurological problems. They cannot afford his treatment either, which his brother has been sponsoring.
In 2023, Diksha complained of severe stomach ache and was recommended for an appendix surgery. But she has not had the surgery yet. “She manages using pain medicine. We cannot afford the surgery right now,” says Lakhya.
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