Why Chhattisgarh’s Healthworkers Are Still Protesting, A Year After Promised Change
Lack of clarity and delayed wages has plagued the state’s community healthcare worker programme for over a year now. Workers are leading a fragmented fight in demanding better wages and regularisation into NHM
For at least two years, Mitanins, the frontline health workers of Chhattisgarh, have been campaigning to be formally absorbed into the National Health Mission (NHM). The programme was, for two decades, implemented by the State Health Resource Centre (SHRC), a state-civil society partnership organisation. Mitanins had hoped that integration into the NHM would bring them a step closer to formal government employment.
So, last August, when the NHM announced that it would take over the operations of the Mitanin programme from the SHRC, the workers believed that it would pave the way for a smooth transition. But the euphoria was short-lived. Soon after, the programme faltered: Workers told Behanbox that payments have become erratic and there is little clarity about how the new system will work. And within months of the transition, the government roped in an NGO to run the programme, creating fresh apprehensions in the cadre.
“Earlier, we used to get all our dues on time but since the NHM has taken over, the payment system has been a mess,” said Lamiya Yadav, a Mitanin from Kawardha’s Pandariya block. In the first few months, the NHM used to send messages providing details about the remuneration, she said, but these stopped after three months. “Now we get random amounts and that too sporadically,” she said.
All the Mitanins and union leaders that Behanbox interviewed reported the same issue. The last payment Kamleshwari, another Mitanin from Kawardha district, got was around Rs 4,000 in July. “I don’t know on what basis they have sent it but I am yet to receive any payment since,” she said.
The Mitanin programme that predates the NHM’s ASHA programme has a distinct structure–women from the cadre are promoted to supervisory roles and also train other Mitanins. These coordinators, who were part of SHRC, also verify and approve Mitanins’ incentives. ASHA workers, on the other hand, are supervised by Auxiliary Nurse Midwives (ANMs), who are employed by the health department.
Workers are now raising questions about the new order that remain unanswered: Will it adopt the NHM practice for ASHAs and make the Mitanins accountable to ANMs or other health department staff? Will the existing system of reporting continue? Could many of them lose their jobs for not meeting the recruitment criteria for ASHA workers as health officials have reportedly told some Mitanins?
Ahead of the 2023 state elections, the ruling BJP, had promised in its manifesto that it would press for Mitanins to be fully incorporated into the NHM and that their incentive would be hiked by 50%. Two months ago, thousands of Mitanins and trainers marched to the capital city of Raipur pushing that the promises made by the party in its manifesto be fulfilled.
However, not all unions participated in this protest–one led by the Mitanins was among these and its representative maintains that the movement should be led by workers, who form the majority of the workforce, and not by trainers and coordinators, fewer in number. While the movement has split into multiple factions, all of them are demanding that the entire system, as is, be incorporated with no mediating organisation involved.
Mitanins, Unlike ASHA
The 72,000 Mitanins (meaning a ‘woman friend’ in Chhattisgarhi) form a crucial link between the community and the state healthcare system. The programme envisioned these workers as the ‘spokespersons’ of communities and their task is to push for their right to health, and help them access healthcare and services. While the state government funded the programme, it created the SHRC to implement it and provide additional technical capacity to the health ministry.
In 2005, when the ASHA programme came into effect at the national level under the NHM, Mitanins were included as ASHA workers with the existing structure of governance and supervision.
The Mitanin programme is different from the ASHA programme in other ways too: unlike an ASHA who serves a population of 1000 population, a Mitanin is selected for every hamlet, irrespective of its population.
By the current projected population of 30 million, on an average, there is one Mitanin for every 400 people. Also, Mitanins are not expected to be literate as ASHAs are. A Mitanin must be a married woman from the local community who is selected by the Gram Sabha and endorsed by the local panchayat. An ASHA worker, by contrast, is expected to be a literate woman with formal education up to 8th class and is selected by the Gram Sabha from three candidates shortlisted by facilitators identified by the Block Nodal Officer.
However, just like ASHA workers, the role of the Mitanins too has expanded considerably over time. But only two years ago, the state government started paying them a fixed honorarium of Rs 2,200 per month in addition to the task-based incentives from the NHM.
India’s 1 million workforce of female community health workers have been instrumental in improving access to healthcare for millions of people and saving lives. Despite denied fair wages and protections, these workers are cementing the healthcare system and ensuring care reaches those who need it most. To mark their 20 years of contribution, Behanbox has launched ‘The ASHA Story’, a special project documenting their lives, tracing the breadth of their work, the politics of their resistance, the economics of care work, and geographies of their rich inner lives.
Growing Workload
The Mitanin programme was introduced soon after Chhattisgarh achieved statehood in 2001 as the newly carved areas had half the number of sub-centres than required and 40% of the posts for Auxiliary Nurse Midwives (ANM) were vacant, according to T Sundararaman, the first director of SHRC who played a key role in designing the Mitanin programme. The purpose was to create a community health workforce but only as an interim measure, he added.
For the first three years of the programme, Mitanins were not compensated for their work for fears that financial incentives would give more control to the state’s bureaucracy and would also defeat the public spirit of the initiative–to improve health literacy and access to services through health activists. This was also meant to dissuade influential people in the community from interfering in the selection process. But the government also recognised that this practice could be exploitative and unsustainable and so the onus of payment shifted to the communities.
A November 2001 government order stated that ‘no honorarium or pay shall be paid to the Mitanin by the Government; however the village community itself can compensate her for her efforts by pooling money or grains’.
In 2006, after the launch of NHM, task-based incentives were introduced. These incentives changed the nature of Mitanins’ work. Activities with readily achievable targets like immunisation and sterilisation took precedence over promoting breastfeeding, maintaining cleanliness and sharing knowledge on better health practices.
“Mitanins were so successful that the government started roping them in for more programmes. Soon, they were given tasks for all national and state health schemes. While this improved Mitanins’ skillset, it also increased their workload,” said Chandrakant, national joint convenor of Jan Swasthya Abhiyan (JSA) from Chhattisgarh.
While the earliest norms required Mitanins to work 8-10 hours a week, a 2020 representative study of 660 Mitanins found that they actually put in 24-33 hours every week, 25% of it on data collection and reporting. Only 20% of the time was spent on core tasks that provided most incentives–linking the community with health services.
As the workload increased, Mitanins unionised and demanded fair remuneration and other benefits. It was only in April 2023–seven months before the state elections–that the state government announced a fixed honorarium of Rs 2,200 per month in addition to the task-based incentives.
When the BJP government won the elections that year, it gave the Mitanins a reason to fight for its demands. “For over two decades, the SHRC had been operating the programme. But after the new government came into power, they said that Mitanins have complained to them against SHRC,” said Chandrakant.
There were multiple issues around SHRC, said Amulya Nidhi, also a joint convenor of JSA. “One of them was that now that the government has changed, they [the government] want to work directly on the programme and not through NGOs,” he said.
Lack of Clarity
The Mitanin programme was structured in a way to provide the workers with autonomy. All of the supervision and training is provided by Mitanin trainers and coordinators at block, district and state level, who are selected from the same cadre.
Additionally, some Mitanins are selected as Swasth Panchayat Samanwayaks (health panchayat coordinators) to provide support to Mitanins and work with the Village Health Sanitation and Nutrition Committees on social determinants of health and some are also selected as Help Desk Facilitators in district and block hospitals.
While the SHRC that operated the programme had representatives from the health department in its governing board, most of its members, including the chair, belonged to civil society organisations and did not come under direct control of the health department. This gave the SHRC a high degree of autonomy.
However, after the NHM was introduced and Mitanins began to receive task-based incentives, coordinators got the additional responsibility of verifying these tasks as well. This system brought about a dual structure of control- the NHM and the SHRC.
Under the NHM’s support mechanism for ASHAs, there is a provision for ASHA Resource Centres to be set up at a state level. “In Chhattisgarh, this centre was located in SHRC since the beginning of the programme and thus all supervisory cadres like coordinators were part of this resource centre and SHRC. The training, regular monitoring and facilitation of all Mitanin work was being undertaken by SHRC under the guidance of the Department of Health and NHM,” said Vikash R Keshari, the executive director of SHRC till March 2025
Now, once the NHM took over operations from SHRC, this structure was affected, creating confusion amidst the workers. “Every programme, every system has a structure. If you completely change that, then the whole system will be disrupted,” said Chandrakant.
As we mentioned earlier, since the transition, Mitanins and trainers are facing problems with their payments. “Earlier too payments have been irregular. Sometimes we would get every month or every 2-3 months but we always got what we were due,” said Suman Thakur, a Mitanin trainer and part of Mitanin Pratikshik Sangh, adding that the payment have been random and erratic in the last year since the NHM has taken over. “Some are getting Rs 3,600, others are getting Rs 8,000. We have no idea who is paying us and how they are calculating it,” she added.
Moreover, the transition has also created apprehensions about how the programme will be operated in the future. Will the NHM continue with the same existing structure or will it adopt the NHM structure of Mitanins and trainers reporting to ANMs? The government has not provided the workers with any clarity.
“During the transition last year, the government had verbally assured the SHRC staff that everyone would be incorporated into the NHM,” said Vikash.
But within months, the government put out a tender and hired Society for Action in Community Health, an NGO, as a partner agency of the State Health Systems Resource Centre (SHSRC) to operate the Mitanin programme. (SHSRC is distinct from SHRC, the latter is an organisation based on partnership between the government and civil society, SHSRCs are resource centres set up in each state under the health mission to provide technical support.)
While the Mitanins that Behanbox spoke to had knowledge of this, they are yet to receive clarity on the role and function of the NGO. Suman, a Mitanin, wondered if this meant that the workers would have to now report to the NGO.
Who Is In/Out?
Lamiya was one of the thousands of Mitanins who took part in the protest in August in Raipur. “Our demands are simple. We do all the work on the field but these contractors [meaning the NGOs] who sit in offices get paid more than us. We do not want the contract system anymore. When we are doing the work, we should get the money,” said Lamiya.
The hope, pointed out Amulya, was that working directly with the government meant scope for permanence.
The 32-day protest ended with the government promising a 50% increase in honorarium but the workers are yet to receive the increased amount. No decision has been made yet about complete integration into NHM. “We protested for 32 days but no one came to listen to us. The NHM director met us but told us that Mitanins cannot be included in the mission because many of us are illiterate,” said Suman.
“Both literate and illiterate Mitanins have been doing the same job so everyone should be included. So many women have spent 10-20 years doing this work, they should not be just cast aside. They should get their dues,” said Lamiya.
The current government is trying to take the Mitanin programme and mould it into the guidelines of the ASHA programme, said Chandrakant. “For the longest time, Chhattisgarh has not had the same party in power as that in the Union government. So each government has tried to strengthen this programme to showcase its work. But now that BJP is in power in the state, they want to just stick to the national scheme and implement that here,” he said, adding that this could mean dismissal of Mitanins and other support workers who don’t fall within the NHM guidelines.
“If they implement these criteria, 70-80% of Mitanins will not be eligible,” said Asha Vaishnav, state president of the Chhattisgarh Mitanin Jagruk Nagrik Manch.
This anxiety has fragmented the fight for regularisation. Asha and others from her union did not attend or support the protest led by Suman and Lamiya’s union. “There are two other groups, both led by trainers and block coordinators. There are 72,000 Mitanins but trainers and block coordinators combined make up for only 5,000 people. So, to build numbers, they have had to rope in many Mitanins. But if they give a letter to the government to regularise themselves, the Mitanins who do the actual ground work will be left behind,” said Asha, underscoring the need for a union for Mitanins to be led by Mitanins.
These differences and quarrels, said Chandrakant, only help the government push back against the workers’ campaign.
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