Backbone Of Its Acclaimed Health Model, Why Kerala’s ASHA Workers Are On Protest
From containing viral outbreaks to collecting data for its various projects, ASHA workers are a critical part of Kerala’s lauded public health system. But the state does not value their work enough, say the health workers now on strike
Over the past three weeks, in blistering heat, Girija R has been traveling around 30 km by bus from Sasthavattom village in Thiruvananthapuram district to the state Secretariat in the heart of the capital city. There, outside the government office complex, the 44-year-old ASHA worker joins hundreds of her co-workers, sitting on an indefinite protest since February 10.
To join the strike everyday, she has to first drop her daughter, who is preparing for her Class 12 board exams, at a friend’s house. She also has no choice but to bring her six-year-old son to the protest site. It is not an arrangement her husband is happy about. On day one of the strike, when she was leaving home, she recalls being stopped at the door by her husband.
“He said if I join the protest I should never return home. But we need the income for our children’s education. So I boarded the bus and came here. It is a fight for self-respect,” Girija says.
Many of the women protesting at the Secretariat travel here from outside the district to show solidarity. Rest is a luxury; they sleep on the footpath, eat the kanji (rice gruel) distributed by volunteers, and take turns to use the few bathrooms in the neighbourhood. They then return home at midday to hastily finish their chores.
The fight for dignity, basic rights, and recognition is at the heart of the strike, called by a section of these community workers under the aegis of the Kerala Asha Health Workers Association (KAHWA). The demands of the striking ASHA workers are clear: in a state that is known for its public health services that depend heavily on frontline workers, they deserve better pay, social security benefits and work conditions.
“Kerala’s health and social service has been ranked first in India, that’s because of us ASHA workers. But our work is invisible, the name ASHA workers is nowhere. We are not able to feed our children or fill our appetites with this salary. Yet we still go to work. Our issues have gone long unaddressed and we were forced to go on strike,” says Girija.
The strike flared up with the demand for the disbursement of pending dues – two months of honorariums (Rs 7,000), and three months of incentives (Rs 3,000). On February 19, health minister Veena George announced that the government had arranged to pay the honorarium without conditions, and that the dues would be disbursed over the week.
Workers are seeking an increase in their honorarium – from Rs 7,000 to Rs 21,000, – assured payment of wages by the 5th of every month, and retirement benefits of Rs 5 lakh along with pension, and gratuity.
“Waiting for the honorarium is like a great hornbill waiting for the rain,” points out Girija, who has been an ASHA worker for the past 18 years since the scheme began in the state.
The workers are also demanding the rollback of a problematic app introduced by the state to track lifestyle health issues among senior citizens, as we explain later.
As Behanbox has reported extensively, ASHA workers across the country bear an excessive work burden. Mostly from Dalit and Adivasi communities, they deal with not just the primary duties they were entrusted with when the programme began in 2005 – monitoring maternal and child health – but also handling additional tasks, especially during the COVID pandemic under exceptionally challenging circumstances. They are also often pulled into election duties. This means combating long and stressful hours that have taken a toll on the mental and physical health of many ASHA workers, as we reported here and here.
For the last 20 years, ASHA workers and other community workers have seen Kerala through crises such as the Nipah virus outbreak in 2018, the devastating floods in 2018, the Wayanad landslides in 2024, and the Covid-19 pandemic.
“Over many decades, across the world, the community healthcare worker has played an essential role in trust building, and creating a sense of ownership in the health system and its institutions. In most programmes, the frontline workers are women and they are exploited in the name of ‘caring heart and voluntary spirit’ in a patriarchal system. ASHAs go beyond the call of duty to fulfil the goals set by the system at great personal cost,” says Rakhal Gaitonde, Kerala-based public health researcher.
Meanwhile, the protest has drawn varied political responses – a contempt case filed against ASHA workers for blocking footpaths, allegations by CPI (M) leader and former Kerala minister Elamaram Kareem that it is “politically motivated” and support from Congress MP Shashi Tharoor. Amid the protests, the National Health Mission (NHM) issued an order to train 1,500 health volunteers to address the service shortfall as during the ASHA workers’ strike , with Thiruvananthapuram and Kollam being assigned to train the largest number of volunteers.
Backbone Of The ‘Kerala Model’
Usha K, an ASHA worker, points out that she and her colleagues are demanding what is theirs by right. “We are the ones who gather information on the senior citizens, children under age five, pregnant women, sick patients. We provide care and help. We have worked round the clock for the people,” she says.
The health system in Kerala is better than in other parts of the country owing to a strong network of primary health centres, says VV Presenna Kumari, the founder and state president of the ASHA Workers Union, and member of the All India Coordination Committee of Asha Workers of the Centre of Indian Trade Unions.
The Kerala model is usually linked with the state’s left politics. “The presence of a strong Left movement in Kerala and its assumption of office has made serious inroads in the caste-feudal system in the state and paved the way for the democratisation of the society with significant welfare components,” Researcher TK Oomen notes in a paper, ‘Development Policy and the Nature of Society: Understanding the Kerala Model’.
In an earlier report, BehanBox highlighted Kerala’s distinct model of decentralised governance and grassroots healthcare, facilitated by the adoption of the People’s Plan Campaign in 1996.
“Since before COVID-19, ASHAs in Kerala maintained a meticulous record of the health metrics of every person under their care: The number of old people and their comorbidities, pregnant women, children between the ages of 0-5, and the number of people with tuberculosis, heart problems, leprosy, physical disabilities and so on….This intricate data collection process was central to Kerala’s test-trace-isolate-support strategy against the Nipah virus,” wrote Pallavi Prasad and Arathi PM in the article.
Gaitonde points to the distinct nature of work delivered by ASHA workers in Kerala.
“In the Hindi belt, which had the most number of ASHAs numerically, the health systems were tackling maternal and child health majorly but southern states like Kerala and Tamil Nadu have reduced their total fertility rate to 1.2, with lower maternal and child mortality. The Kerala government in 2008-9 was interested in using ASHAs to progress with its work on non-communicable disease,” says Gaintonde. ASHA workers thus also monitor those with chronic illnesses that require constant followup and care.
Gaitonde points out that the neoliberal economic policy that the country adopted since 1991 in its push for greater privatisation does not support job security and ASHA workers suffer the consequences of this. “They are not isolated in this, it is the same for Anganwadi workers and the [temporary] teachers in the education system. ASHA workers continue to be called ‘voluntary’ and are treated as temporary workers. This is despite the concern that critical aspects of development like education and health cannot be carried out by using an insecure precarious workforce,” he says.
While Kerala has historically rejected neo-liberal, free-market oriented policies and aimed at improving, state-funded public health infrastructure, it extracts labour from women, as Behanbox has pointed out.
‘No Money For Groceries, Mounting Debts’
Till 2016, ASHAs were paid a monthly honorarium of Rs 1,000, this was then increased to Rs 7,000, a fixed sum that comes from the state government. They also receive an additional fixed amount of Rs 3,000 from the central government, (this is shared by the centre and state in 60-40 ratio) Additional incentives for tasks such as immunisation can earn them up to another Rs 3,000, depending on number of tasks and the population serviced. But this is simply not enough.
“Come rain or sun, we are working. But we still cannot make ends meet. My husband is a daily-wage worker so we depend on this job for life, and even to take loans,” says K Usha, an ASHA worker in Rajaji Nagar, Thiruvananthapuram.
Sreekutty from Ernakulam’s Cheranalloor, says she cannot afford to join the strike in the state capital. “We don’t earn enough to buy a bus ticket there to Thiruvananthapuram. My co-workers struggle to manage with this salary and the delays in its payment – they take loans, are unable to pay rent, can’t complete construction of their own houses, buy basic groceries, have no money to pay for gas cylinders,” she says.
Up to 51% of ASHA workers of the 201 interviewed across states by Behanbox for its survey, Female Frontline Community Healthcare Workforce in India during Covid-19, reported experiencing two to six months delay in payment of their wages during the pandemic.
“Lockdown and pandemic-related job losses of other members of their families has led to further economic vulnerability. On an average, ASHA workers reported debts ranging from Rs 10,000 to Rs 40,000 incurred during the pandemic. In some instances, ASHA workers reported a debt burden of over Rs 1 lakh,” the report said. This crisis pushed them into selling household assets and pawning jewellery to meet household expenses or borrowing from self-help groups, family members, and co-operative banks.
Long after the pandemic and the lockdown ended, several ASHA workers continued tackling mounting debts, and unsteady incomes, Behanbox has reported. M Usha from Thiruvananthapuram says she has to repay a bank loan of Rs 3 lakh and several other small debts and that she has had to pledge her gold ornaments as collateral.
Covid And Tech Travails
A major demand of Kerala’s ASHA workers has been the rollback of the OTP system on the Android Shalli app. Developed by the state’s digital health mission and pioneer project, eHealthKerala, the app was introduced in 2022. It aimed to diagnose and control lifestyle diseases while collecting information on ailments from diabetes to cancer.
The backbone of the data collection process was the ASHA workforce, tasked with reaching out to homes with a handy set of survey questions. The first phase was deemed a success, with the community healthcare workers surveying over 1.5 crore people.
According to a study ‘Digitisation at the Frontlines, ASHAs’, Experiences across Haryana, Rajasthan, Kerala, and Meghalaya’, digitisation has aided in communication and coordination among ASHAs. But it has also been constrained by limited access to quality digital devices, low digital literacy, poor training, and a lack of trust in digital tools.
“Digital workloads have increased, particularly unpaid digital labour, and working hours have extended, with a growing shift from community care work to digital data collection and reporting,” found The Institute of Social Studies Trust (ISST) study.
The data work, says Usha M, has doubled her workload. What took 15 minutes now costs her an hour of effort.
“In the first phase, we could link respondents on the app with Aadhaar, voter ID, and passport. But in the second phase, the app would open only through Aadhaar, and those (respondents) who registered without it were not found on the app,” says Girija. “But sometimes the person doesn’t get the Aadhaar-linked OTP or even if they do, there is a lot of mistrust about sharing it with us.” Without this OTP, the workers are unable to reach the questionnaire portion of the survey.
“The government told us we need to finish the second phase by February, but at my centre, the process started only in January,” says Usha.
While ASHA workers carry out state-specific tasks, the health minister Veena George said that it was up to the Centre to do what was right for the ASHAs, and that in the 2023-24 budget the Centre had not even provided the State with the latter’s share of the incentive payment for ASHAs, worth Rs 100 crore.
The protest continues to rage on with workers conducting a massive march on Monday. “There is critical backlash from parties and ministers but this has not shaken us,” says Girija.
Behanbox has sent a questionnaire to health minister Veena George, seeking the state’s response to worker demands. We are awaiting a response, and this story will be updated when we receive one.
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