‘Day And Night We See the Problems of ASHA Workers And Women in Our Society’

Take us back to 2005. What made you want to join the ASHA cadre? 

Since childhood I had dreamt of becoming a doctor. When I heard the ASHA role was associated with the health department, I thought it could be a step in that direction. I had only studied up to the 10th grade – education for girls wasn’t mandatory in our area – but I hoped that if I kept going, I could study further, take exams, maybe even qualify for the Pre-Medical Test someday. And at the very least, this job would allow me to study without asking anyone for money.

Back in 2005, the programme didn’t really get off the ground. It probably reached the departments for implementation and showed up on paper reports. But in reality, at least here in Madhya Pradesh, it wasn’t active and no appointments were made before 2006. Proposals for appointing ASHA workers reached the gram panchayats but even they didn’t really understand much about it. The panchayats handed over the selection process to the local NGOs – tasks like issuing tenders – which then identified candidates, often from within their own networks.

At that time, there weren’t even proper forms to apply, and it was done by submitting a basic motion during the gram panchayat meeting. In my case, my chacha and sasurji (father-in-law) were panchayat leaders and they submitted a proposal, noting that I am 10th pass. The panchayat agreed and that’s how my name was picked. 

The selected women would then go to the NGO, where they held something like an interview. They would just ask you to write a shapath patra (oath), agreeing to be part of the programme. That’s it. If someone could write clearly and quickly, it was assumed they were capable enough to be an ASHA worker. If someone couldn’t write but had no other competitors in their village – because not many wanted to do this work – they’d still be selected.

Honestly, at that time, no one had a clear understanding of what this programme was – not the gram panchayat members, not the government departments, not even the health department or the NGOs. No one knew how it would function, how incentives would be structured, or what kind of work would be required.

How was the role perceived within the community? And what did you make of it after the selection process?

There were all kinds of misconceptions at the time. One was that this was similar to that of a dai – that it involved childbirth and applying oil during deliveries. Another misunderstanding was that it was an official government health worker job – some people thought a proper Auxiliary Nurse Midwife (ANM) was being appointed.

It was only after the initial appointment, when we went through the first round of training, that a doctor madam explained that there was no fixed salary involved and this was to be voluntary work. Even she didn’t share anything from her own experience; she only read out and clarified what was written in the training module. The language around ‘incentives’ was difficult for us to understand so she explained that we would be paid based on tasks completed, and that we had to do whatever the government instructed.

We were told there were only two main responsibilities: supporting immunisation and assisting with deliveries. Even the trainers didn’t fully understand the broader role of the ASHA worker. I thought if it’s just these two tasks, I can handle it. Lekin mann mein dukh toh hua. It was confusing and disappointing. Yeh kya kiya humne, aise thodi kaam karna tha? We wondered what we had signed up for. This wasn’t a ‘job’ job, and the training itself wasn’t particularly helpful.

What were training programmes like? How did they articulate the ASHA role? 

The government training was quite superficial – maybe an hour or so of reading from the manual, and then the rest of the time was just sitting and doing time pass, signing attendance, and leaving. This continued for the first two years; we didn’t receive any clear information or direction.

A whole year passed like that. One day I went on my own to the local Anganwadi center and met, for the first time, our village’s own ANM. I didn’t know what to do there either, so I just sat in the room for a long time with my ghunghat on my head, and then went back home.

Eventually, more training sessions started and things became a bit clearer. The first thing we understood was that the ASHA worker’s main responsibility would be to support all health-related activities under the health department – focusing on institutional deliveries to reduce infant and maternal mortality rates, and actively participating in immunisation efforts to prevent diseases and reduce malnutrition among children.

One time I spoke to another ASHA about the institutional deliveries work: when a woman goes into labour, we have to take her to the hospital. I wondered if that was our only role. She explained that deliveries shouldn’t happen in the village and should take place in a proper medical facility. Even after the initial training, we didn’t really understand how we were supposed to motivate women to go for institutional deliveries. We didn’t know that there were things we were supposed to do before the delivery – like arranging for the four antenatal checkups, ensuring the two vaccinations are done, and so on. But we began to understand this better as the training modules continued. Then ration distribution training also started, and that’s when we really started grasping how we were expected to work and maintain records.

We also learned that family welfare was part of our responsibilities, and though it only had three main focus points, it actually involved a wide range of tasks. This included encouraging people to adopt family planning methods; we were expected to motivate both women and men to consider sterilisation, use PPIUCDs (postpartum intrauterine contraceptive devices), oral pills, and condoms. Training mein yeh cheezein sunne mein sharam aa rahi thi. It was difficult to even listen. I was still one of the more educated women there so I didn’t feel too embarrassed but the other women – some of them covered their faces with their saris, looked down, or put their hands over their mouths. 

Meetings were rare and mostly task-based. Those meetings weren’t really designed to inspire ASHA workers or teach them anything new. They were more like briefings. “Pulse Polio campaign is coming up. You have to administer the drops. This is the VVM (vaccine vial monitor), this is how the vaccine carrier box is to be handled, and this is how to maintain the cold chain.” That was it. It felt like we were included just to fulfill their quota. 

Later, the training responsibilities were shifted to the NGOs and their guidelines were much better. The ASHAs who lived near the block office or district center, and were somewhat more educated, started picking up things faster. They were often called first whenever there was a meeting or event nearby. Eventually, when we began meeting in those gatherings, we started learning from one another.

What sense did you make of this distinction between ‘volunteers’ and ‘employers’?

Shuru mein samajh mein nahi aaya, lekin krodh aaya (I didn’t understand at first either, but I was very angry). It’s wrong – to work and not get paid. I connected with some NGOs who explained about the National Health Mission (NHM) and the ASHA programme, and about other scheme programmes like Anganwadis. I also learned about women’s empowerment and child development programmes. People who worked there explained how the WCD started similarly, with no incentives for each task, or workers got a small amount from the state and from the department (around ₹200–250, same as us). I was inspired in a way. If they have been making do with this and they’ve been doing this work for 40 years, we should keep doing it too. Eventually, we will get incentives, fixed pay, or something else. 

Plus, this work is good because you can do it part-time and still do other things like teaching tuition or teaching part time. I worked in a private school, teaching Hindi and Social Science to 10th graders. I learned a lot myself, for instance, how to communicate with children effectively. Secondly, I found knowledge in social sciences and history to help me understand the roots of many things. I also got better at writing quickly. I used to practice writing down things from TV programs, like old shows, news, songs on channels.  

I fell ill in 2009, and by 2010, I had completely stopped teaching. After that, I started giving more priority to ASHA work.

What challenges came with the nature of this work?

Taking the women to hospitals wasn’t easy – there were conflicts. In the village, trained dais, who had long handled deliveries even before the ASHA programme began, wanted to stay involved so they could be paid. At that time, there was no HBNC (Home-Based Newborn Care) programme so the ASHA worker’s role was strictly limited to getting the woman to the hospital. Families believed ASHA workers’ only job was to get the woman registered at the hospital and help secure the incentive payment. They were thus inclined to turn to dais for postnatal care, massages, or when complications arose, or they called unlicensed jhola chaap doctors (quacks).

Whoever accompanied the woman would get the payment – so if the ASHA arrived late, or if the family preferred to give the money to the dai, the ASHA worker wouldn’t get anything. This hit ASHA workers’ motivation.

Another issue was there was no bank transfer system – all payments were made in cash. And half of that cash would often be taken by dalals (middlemen) – the people who were handling the disbursements or accounts. There used to be several quarrels. I remember once I signed off on a payment without counting, only to realise I had been shortchanged. I marched back to the PHC and tore the payment record sheet – my first real fight against the health system. I finally got my full payment, and that gave other ASHA workers the courage to speak up. We formed a group, started raising our voices and eventually, payments became more regular and transparent. 

Still, as long as we were paid in cash, these corrupt agents kept skimming off money. Uss zamanein mein, ASHA workers didn’t even know how to count money, and even now the payment situation is very bad. Despite direct account transfer payments, the manipulation continues, even when the payments are from the National Health Mission. If an ASHA worker’s monthly incentive totals around Rs 10,000 or Rs 12,000, they find ways to deduct money or complicate paperwork; they twist and break it up so much that we never get more than Rs 6,000 in hand. ASHA workers today who are very educated and hold postgraduate degrees; still they aren’t getting full payment. 

How did your family respond to all this? 

Our families told us to quit. “All day you’re running around after beneficiaries, and for what?” they said. “Ghumne ka shauk milta hain bass (you only get to enjoy travel).”

Sometimes to protect our dignity, we would lie. If someone asked what we did, we told them we were associated with the health department. If they asked how much we earned, some would say Rs 2,000, some Rs 4,000, others Rs 5,000 – just so that people wouldn’t look down on us and think that we do all this work for just Rs 100 or Rs 200. 

Both (my father-in-law and husband) thought this was going to be a big government job – like ANMs – and that it would bring in Rs 20,000 a month. Men assumed that they’d do the work while the woman’s name would be on the records and the household would benefit. But they didn’t know that this kind of job had no guaranteed income. When they found out, they rebuked me for “wasting” my time and ignoring the household. I had to lie to stay put: I told them I can’t leave before 10 years because it was government work. 

By the time those 10 years passed, I had become a supervisor, and everything changed. Now the payments were regular, people accepted the role, and everyone understood. I had also established myself by then. 

You said you wanted to become a doctor. Where did this dream come from? 

I was very young when my grandmother went for eye surgery at the hospital. There I saw girls wearing an ANM apron but I didn’t know the difference between AM (Auxiliary Midwife), doctors, or staff nurses. Or multi-purpose workers. I only knew that in the hospital, whoever wore a half-apron was a junior doctor, and the full apron was a senior doctor.  I saw doctors working so hard, talking nicely to so many patients, giving out medicine and helping everyone get better. When my grandmother was discharged, she gave Rs 100 and many blessings to the ANM who had cared for her. I marvelled at this: are doctors so kind that people always bless them? I wanted to become a doctor at that moment. 

But in our Chambal area at the time, there was a mental barrier among people allowing girls to leave home to get an education. Mostly caste privileged groups – the Brahmins, Jains, Baniyas – were getting educated but the daughters of Thakurs and other castes were not studying much. My father worked at a power house in Gwalior but his mentality was still rooted in the village mindset. My mother didn’t want me to study too much but I insisted.  

I had to give in eventually. By tenth grade, I was married. After that, I stopped studying and started focusing on household work. When I reached my in-laws’ village, forget about studying, I even forgot to look after myself. We had to cook food on chulhas and there were no latrines inside the house. My first hunger strike happened at my in-laws’ house — I demanded that we build a latrine. I fought for two years for it.

Did it seem like a burden – care work at home, and care for the community? 

I initially thought I would die of exhaustion. I had to manage the vaccination schedule too, and I wondered how I would manage everything. Many times, I got so tangled in work that I couldn’t even go out — I had to clean wheat, wash clothes, and sometimes missed vaccination sessions. 

It affected me mentally. I had to maintain records, but no one helped me. Other ASHA workers got support from their husbands. Mine told me to quit. He also drank a little, and he didn’t want me roaming around the village. Once, a cooperative bank came to the village for recruitment. My form was submitted, but the final selection required a bribe of Rs 3,000. My father-in-law and husband refused to pay. Tum kursi par baithogi, aur hum tumhari ghulaami karenge? I didn’t get the job, but if I were the manager, I’d be earning Rs. 1.5 lakh a month. 

When they learned more about the work I do – where I had to go outside and talk to men outside of my family – they insisted I quit. There were fights about this. Bahut mann lagta hain tumhara dusre aadmi se baat karne mein. Ghunghat kyun nahi pehena (you enjoy talking to other men…why aren’t you veiled)? But I had to save my job from the family.

These problems were being faced by other ASHA workers too and we spoke about it. It was slightly less rigid for women who belonged to SC/ST communities because their caste-based work involved public, visible work. For example, the women who sweep streets or do cleaning are from marginalised castes, and these women and their families are used to going out for work. 

For some women, becoming an ASHA was a big opportunity; for others, it was a challenge; and for some, a way to establish themselves. For me, these three things happened together.

Was there camaraderie among the ASHA community?

I only knew about a few ASHA workers from the nearby villages – two or four, maybe – but I had no information about ASHAs in other blocks or districts. Back then, mobile phones were not common; hardly anyone had a personal phone, especially women. We would occasionally meet during training or meetings, and exchange numbers. The ASHA workers didn’t have personal mobile numbers so we would end up sharing our husbands’ phone numbers. Most of the time, I was the one initiating contact and calling others, especially because I was working in a very remote area.

Our block is located at the intersection of Madhya Pradesh, Uttar Pradesh, and the Bundelkhand region. It is one of the most backward and isolated areas. Even today, awareness there is quite limited. Once you start stepping out for work, change happens naturally, but in the beginning, no one was interested and the women wanted to quit. I also felt like that at times but at least I was connected to something, Log toh milte hain iss kaam ke bahane. Even if we don’t manage to educate others, we are getting educated in this process. And whenever we met during meetings, we would try to motivate one another. 

What did you do with your first payment?

Our first payment was for the entire year of routine immunisation (at about Rs 150 per session, which included some of my institutional delivery incentives too). We didn’t get monthly wages before, it was either after six months or a year. All together, it came to around Rs 1,800. Actually it was Rs 2,400 but they cut Rs 600, which is what led to the big fight I mentioned earlier. I eventually got the full  Rs 2,400. Usually other people give you money – either your husband or family – and it comes with many conditions. But this money? It was for my work; I could do anything with it. At the time, Rs 1,800 was a lot. I thought: “Should I buy clothes? Something for the children? Something useful?” But when I got home, I decided not to spend a single rupee. I saved it. I later invested Rs 5,000 (added a little bit myself) in a fixed deposit with that amount.

But then I fell sick. I was diagnosed with cancer, early stages, and had to travel all the way to Delhi for treatment. Those savings helped me get treated. I had two operations, and now I’m fully recovered. Although I don’t fall ill easily, whenever I do fall sick now, I’m bedridden for days. I think my immune system was weakened. Still, I never let it affect my work.

I made up my mind to stay in this programme after I got sick. When I had cancer, there were five of us undergoing surgery and we kept in touch. I noticed that by the fourth follow-up visit, no one else from our group was alive. I was the only one left. I made up my mind. If God gave me this life, there must be a reason. I have to do something meaningful with it.

By 2011–2012, I had fully recovered and kept working throughout. The system wasn’t as rigid back then and there wasn’t as much pressure, and there were days when I didn’t do my best or with as much sincerity. Before that, I was just living simply – cleaning, eating food, making food for others, but now I felt like I had to do something special. 

Was this also the time you got a leadership role, and into organising?

Yes, the post of ASHA facilitator came up in 2012, but I initially didn’t apply due to childcare responsibilities, health issues, and the travel the role required. Later, an officer from the leprosy department encouraged me and said: “You’re more educated, active, and capable than most.” By then, I had completed my 12th and was trying to study further. I applied and was selected.

Earlier, as an ASHA worker, it was hard to convince others or assert myself – har ASHA barabar hai, so it was difficult to persuade or explain things to each other. But the supervisor position legitimised the work and created some structure; that kind of influence or leadership wasn’t possible earlier.

I wanted to channel this into building a larger movement. As a facilitator we were trained in leadership skills too: how to motivate ASHAs, how to support them in their work, how to engage the community. I also began connecting with NGOs and other departments, especially in Women and Child Development. They helped me get connected in the right places, gave me knowledge and confidence. Everyone contributed to both building this organisation and building me. Eventually, I gained that sense of identity – of having a voice, of having a place. 

The first thing I learnt was communication, how to talk, how to speak with officials. Sure, we will fight if needed, but there’s a way to fight and I learned that how you talk matters. Or that there’s a way to write an application or memorandum or a complaint. We learned to explain, for example, that if we don’t get access to forms or medicines, it also harms the community and hampers our work. 

We also learned the art of public speaking. That knowledge came with this programme offered by the Community Leadership Capacity Development (under the Jan Abhiyan Parishad), and another women’s empowerment programme. 

We organised our first public memorandum in the block on March 8, 2017, on International Women’s Day, and within four to six months, we expanded the work to the whole state. 

Who were the figures that inspired you?

Since childhood, I really admired Indira Gandhi and Rani Lakshmibai of Jhansi. The fighting spirit of Rani Lakshmibai definitely became a part of me. Everyone says I got my fighting spirit and stubbornness from my father. My mother was gentle and forgiving. I speak my mind and tell people when they are wrong.

But I didn’t have Indira Gandhi’s administrative or leadership finesse. I knew how to protest, argue, make my voice heard – but I didn’t know how to do it effectively. Now, I’ve learned how to speak persuasively. For example, earlier we struggled to explain to ASHA workers why they should care about pay cuts or medicine shortages. But now I can piece together the context and explain it to them. Our work and role is in question if patients from our area keep appearing in OPD lists of private or government hospitals. 

With the ongoing issue of privatisation of health services, initially, we used to think—“What do we have to do with this? Our job is to raise ASHA-related issues.” But Amulya Nidhiji from Jan Swasthya Abhiyan explained to me how this is not just an issue for the general public, it affects us well. In turn, I was able to in turn explain this not only in our area but across Madhya Pradesh.

Since your work involves a lot of interactions with women and families, what did your relationships look like with them?

We’ve built very strong connections with the community. We’ve always participated in women’s empowerment programmes like the Shaurya Dal, and especially in Beti Bachao, Beti Padhao campaigns in our district. 

But back in 2007–2009, when I had just started, talking to families, especially women, was really hard. The same people – sasur, jeth, devar — around whom we wore a ghoonghat, we were to now go and talk to them, educate them? 

I found a way through the kishori balika programme (a scheme for girls and schoolchildren) in the community. One time our ANM asked someone to deliver iron tablets to the school but she didn’t directly tell me because she knew no ASHA or Anganwadi worker would go, it was assumed that their husbands would go instead. But I went myself. The teachers at the school were from our community, and purdah was still practised, so I didn’t speak to the male teachers directly, but they sat around and listened. I explained everything I knew about iron tablets. The teachers appreciated it. The students were happy and I came back with a beaming face. The Anganwadi workers said the next time they would come with me too. 

Talking to adolescent girls and boys helped, because they went home and told their families that ‘Lakshmi didi from our village gave this to us’. My name began to spread and some women got in touch; I started inviting them to meetings, and would regularly meet with them every couple of months. ASHA workers later from neighbouring villages asked me to help organise meetings in their areas, and I would sometimes make an excuse to my family to attend these. Now as a supervisor, I go in an official capacity but back then, I just wanted to go and help other ASHA workers, meet people and build connections; just this idea: logo se milte jaaye, pehchaan padhti jaaye, sambandh badhte jaayein. 

Given the distrust in the public health system, how did you gain people’s trust?

Initially, I didn’t push the medicines. When I started connecting with the women, I focused more on government health schemes where there was some financial benefit. Once they began to believe and trust me, they started asking for help. For example, there was a Muslim woman with four daughters whose husband had passed away from cancer. She was arranging a double wedding for two of her daughters and she asked me for help. There was no formal scheme but I connected them with an NGO that helps with weddings for underprivileged girls. The whole community was so happy. Eventually, people started trusting me with everything.

Jab dawai-goli ki baat aayi, the community started to accept ASHAs more. Because there were no roads or pharmacies in the village, no doctors nearby, so when someone was sick, they had to go to the ASHA to get medicines. Bahu, tumhare paas dard ya ulti ki dawa hai? 

Even with medicines – iron, calcium, zinc – I explained these are not for illnesses but nutrients people often don’t get through food. Sometimes I would sit in front of people and take the tablets myself; only then they realised nothing bad would happen. We would tell older women complaining of joint aches about the importance of calcium or drinking milk to strengthen bones, but many would say they don’t have milk at home. I gave them calcium tablets and many said they felt relief. Doctors or scientists might not believe that a calcium tablet cures joint pain – but faith matters. 

As a community worker, what did you make of the purdah pratha (veiling)? 

I still wear a ghoonghat occasionally, but not like before. 

In 2012, at a water sanitation meeting organised by the Jan Abhiyan Parishad, I sat there the entire time with my ghoonghat on, not saying a single word, even though I had organised the whole event myself. Later, in 2016–17, when I started forming organisations, I realised I can’t lead from behind a veil. I still couldn’t remove my veil in my own village, but I did in neighbouring villages – which were full of relatives. There were 42 villages around us where we had ties: sisters-in-law, cousins, uncles, in-laws, and I decided to gather courage outside. If someone did recognise me, I’d just turn a bit to the side, but I didn’t cover my face again.

This news made it back home. Aise ghumti phirti ho. I told them I don’t know who they are and I’m just doing my work. In front of the officers, I had to go and speak – I couldn’t afford not to. There were fights at home but I kept moving forward. 

Then on June 7, we organised a special community program just for our caste group. I had been thinking that I would work  for ASHA workers, the broader community, even different departments and NGOs, but I haven’t done anything for my own society, which is still rooted in superstitions and customs. The event was targeted at women in particular and organised around a culturally respected figure – so no one saw it as political or ideological. By that time, my relatives had also accepted that they might as well support me. And many actually helped – even respected elders from the community. In the middle of that programme, for the first time, on the stage in front of my family, I lifted my ghoonghat. I knew I wouldn’t get another chance like this so I spoke about gender, religious issues to gently challenge these traditions. I created a WhatsApp group later and it’s very active. Someone invited me to a baithak on a Sunday. Another person advised me to start preparing for elections. 

Does caste play a role among ASHA workers? 

In the beginning, ASHA’s work was not seen as respectable – people thought it was similar to a dai’s work which is usually performed by marginalised caste women. Being a dai is important, people didn’t respect the idea of women roaming around applying oil, assisting deliveries, and doing ‘dirty work’.

At that time, mostly women from SC/ST communities applied and were made ASHA workers.  They accepted the job out of necessity, and when they started getting paid – even if just a little – they stuck with it. The upper caste Thakurs and Brahmins didn’t push their daughters-in-law into this work. 

It was and still is difficult. People wouldn’t let them inside the house; they were made to sit outside on the doorstep to talk; they wouldn’t talk to them properly, wouldn’t even drink water from their utensils fearing they’d be ‘polluted.’ Because of these reasons, ASHAs couldn’t be very active in the community at first and felt freer to visit families of their own castes only. 

How did you find time to rest or care for yourself amid this care work? Is there something you wish you could do more often when time allows?

On days when I get time to myself, I feel like we haven’t done anything — like I didn’t really live that day, didn’t even breathe. Even if I don’t get to do good work, just sitting and talking with just two people feels enough at times. I  have so many social groups, community groups, and we are active in all of them. If someone has a problem, we immediately try to understand and respond, or say, “Wait, let me check what else we can do.” It feels like I’m working like a machine but it weirdly feels good to call ourselves that – to say I am active, and I don’t know when or how much we sleep. It makes me happy and proud. 

But if I had the time, I want to do a PhD. I had a dream of becoming a doctor — even if not a medical doctor, I could be a doctor in name at least and perfect my knowledge in some subject. Maybe in the field of health or politics, or a combined subject. Because politics isn’t just about contesting elections and it doesn’t happen only by joining a party. We want to do a kind of politics where our leadership brings something good. We are connected to people and their problems — we see the problems of ASHA workers day and night, and the problems of women in our society. We want to improve these issues. I don’t know if I can do it right now, but soon.