The Women Warriors Fighting COVID-19 at the Frontline: ASHA workers left without Hope

Amnesty International India
21 May 2020 7:25 pm

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Pratima*, a 39-year old ASHA or Accredited Social Health Activist starts her day at 9 in the morning. Without any personal protective gear, she sets out, visiting door to door, checking whether anyone has cough, fever, or other symptoms. If there are any, she takes them to the nearest health centres. In the next ten hours, she covers over 30 houses, sometimes 50 reaching out to the community, checking on them and advising them on how to keep safe. Next day, she sets out again.

India’s crippling health system is today at the forefront of the country’s battle against the COVID-19 pandemic. At the very centre of this public health system, stand over 900,000 women called as ASHA workers who are taking on the pandemic – unarmed, unseen and unheard.

ASHA worker is a community health worker or the first point of call for any health-related demands and concerns of rural and now even urban India. For little remuneration, they carry out the enormous task of bringing the inaccessible public health system closer to the disempowered community by facilitating awareness on healthcare-related information and improving utilisation of existing government schemes and services.

As the COVID-19 pandemic unfolded in India, the responsibilities of the ASHA workers were expanded while little was done to strengthen their paralysing social and physical protection. According to the Ministry of Health and Family Welfare’s Model Micro Plan for Containing Local Transmission of Coronavirus Disease (COVID-19), ASHA workers were deployed to conduct house-to-house visits to curb the pandemic. They are to report symptomatic cases, then carry out contact tracing, maintain documentation, monitor the situation and create awareness about the pandemic in the community. The data presented to us on the COVID-19 cases every day from ground zero, i.e. each state, village or ward is largely the work and toil of the same ASHA workers.

Amnesty International India spoke to over eight ASHA workers and members of ASHA Workers unions across India to understand their concerns and demands, in wake of the pandemic.

All Work, No Protection

Over the last two months, the instant association of the term ‘health-workers’ with nurses and doctors has made us honour their work, appeal for their safety from the safe spaces of balconies and celebrate this commitment on social media. Amidst this glorious trail of displays, the appeal for protection for ASHA workers, who are also health-workers has remained conspicuously absent despite many ASHA workers sustaining continous physical and verbal attacks from the community, testing positive for the virus and fronting burnout across the length and breadth of India. 

Sharing her anguish with Amnesty International India, an ASHA Worker from Maharashtra’s Surul district said, “We go every day and ask questions to people whether they have any symptoms. But we are totally exposed without any mask, gloves etc. The shawl I tie across my face is just something for my solace. It won’t really protect me, I know.”

On 20 April 2020, the Ministry of Health and Family Welfare in its guidelines acknowledged the plight of healthcare workers. It directed the state governments to ensure proper provisions of Personal Protective Equipment (PPE) for health care workers and delivery of timely payments to them. It also stated that healthcare workers examining confirmed yet asymptomatic cases of COVID-19 without adequate protection would also be tested.  For ASHA workers specifically, however, the bar of protection is set lower than the other healthcare workers. The Ministry’s guidelines on ‘Rational Use of Personal Protective Equipment’ classifies ASHA workers as ‘low risk’ among health care workers recommending only triple layer masks and gloves for their protection. However, in reality, it has been a struggle for the ASHA workers to even secure this minimum protection.

“We were asked to go to the hotspot area of Islampur where 22 of a 25-member family had tested positive for the virus. Many ASHA workers refused to go, but I agreed. I know this work is important. We were sent there without any masks or gloves. It is only after we gave a TV interview, we received 10 masks each. It is an ordinary mask which we wash and keep using again since we have not been given more”, one of the ASHA worker working near Islampur in Sangli District, Maharashtra told Amnesty International India.   

After several media reports exposed the working conditions of the ASHA workers, some states provided them protective masks.  But in many places, ASHA workers are still dependent on the mercy of the gram panchayats (village council) or city corporations which in turn rely on the district administration. This has led to some panchayats receiving safety equipment while others continue to wait. Even those who have received, gloves remain largely absent from the equipment.

In some states protests have helped but fear of reprisals from the local adinistration loom large in the minds of the workers. In Haryana, the ASHA Workers Union stopped work and staged a protest when one of their fellow worker was tested positive for the virus but did not receive proper facilities at the hospital.  Because of the protests, she was shifted to a better facility.

Overburdened and Underpaid

Even though remuneration of ASHA workers differs from state to state, they largely remain poorly paid. They receive a monthly fixed wage and incentive based on promoting reproductive and child health, universal immunization etc. Their ‘salary’ remains abysmally low with their core incentive scoping between INR 2000 (US$26) to INR 3000 (US$70) in most states. The other wages are based on various schemes wherein they get income based on assisting pregnant women for institutional delivery. These conditional wages are often delayed and ASHA workers receive a round sum after two or three months of working tirelessly on the ground. The COVID-19 relief work has further expanded the list of their deliverables for a paltry and inadequate additional remuneration of INR 1000 (US$13).

Speaking to Amnesty International India, an ASHA worker who is also a single mother from Pune, Maharashtra said, “They say that the government has announced an additional INR 1000 for COVID-19 survey work. I don’t know if it’s true but that is very less. We are risking our lives here. I have a child and I am also the sole bread winner of the family. I am very afraid for my child’s life.” Another ASHA worker said, “On regular months, besides the INR 3000 we get, we earn extra by doing other work like delivery assistance and vaccination. But now because we are only involved in the COVID-19 survey, we are not able to go for such work which is greatly affecting our already little income.”

The difference between the minimum wage allocated by the Government of India and the actual remuneration reaching the pockets of ASHA workers is vast. According to the 2018-19 Economic Survey, the notified minimum wages in states/UTs across India averaged at INR 422.97 (US$5) per day with Nagaland at the lowest with INR 135 (US$2) and Kerala at the highest with INR 1192 (US$16). However, as demonstrated above, in practice, the remuneration received by ASHA workers is far lower in most states.

The ASHA Workers unions have been standing up for their members across India without much success. To illustrate, in their Labour’s Day appeal, the Delhi ASHA Workers Union demanded a minimum of INR 750 (US$10) per day for the women involved in COVID-19 related survey and also an increase in their permanent core incentives. In Maharashtra, the ASHA union affiliated with the All India Trade Union Congress (AITUC) also demanded an increase the remuneration of ASHA workers to the minimum wages the state has allocated for skilled workers.

Speaking to Amnesty International India, Shankari Pujari, Secretary of Maharashtra ASHA and Block Facilitators Women’s Union said, “The government raised the minimum wages last year for all unskilled, semi-skilled and skilled workers. But the wages of ASHA workers continue to remain low. We have been submitting this demand for many years but to no avail. The government refuses to even acknowledge the ASHAs as part of official definition of “worker” under relevant labour laws and therefore conveniently escape from their obligation of addressing the concerns of the workers. Now, the ASHA workers are putting their lives at risk without being adequately compensated.”

Since the outbreak, various state governments have made positive reforms to motivate healthcare workers. But most of them either explicitly exclude ASHA workers or fall short of providing any kind of real-time protection to them. For example, the Haryana government announced that the salaries of healthcare workers would be doubled but ASHA workers did not find a mention in the list.

“Do we not risk our lives too? Are our lives not important?” ask ASHA workers of the Maharashtra ASHA and Block Facilitators Women’s Union.

Similarly, while the Government of India has announced an insurance for all health workers as part of Pradhan Mantri Garib Kalyana Package up to INR 50 Lakh (US$66,190) in case of loss of life due to COVID-19 related work, it fails to take into consideration the risks faced by the ASHA workers on job.

“Of what use is the insurance when our lives are lost?” asks Shobha Shameel of Pune ASHA workers Union. “The ASHA workers do not have any other social security protection and they are expected to afford treatment themselves with these low wages.”

Earlier the ASHA workers were allotted a population of 1000 each in case of rural areas and 1000-2500 in urban areas. Since the pandemic, this allocation has been expanded and now they have to cover other neighbouring areas including the hotspots and containment zones, further aggravating the risks faced by them. This has not, however, led to increase in any kind of social protection to the workers. 

Domestic Violence and Protests

According to the National Health Mission, ASHA workers are residents of the same village or area where they work and preferably ought to be in the age group of 25 and 45. They are also required to be formally educated until 10th standard and undergo a series of trainings to become an ASHA worker. Essentially, these women are from the same community, facing similar socio-economic struggles while continuing to expose themselves to the harsh consequences of the pandemic.

Swamped with guilt, many ASHA workers are shut out from their family for working in precarious working conditions and putting the lives of their families at risk. “What will we get out of this? For a paltry amount of INR 3000, we are putting the whole family in danger. My husband blames me every day,” said one ASHA worker from Delhi on a condition of anonymity.

Door to door surveys also bring along a strong sense of stigmatisation. The negative association of ASHA Workers with the virus has led the community members and family members to view their work as that of spreading the pandemic instead of curbing it. Speaking to Amnesty International India, Urmila, an ASHA worker said, “I have been sleeping on the veranda outside at night. I have a two-year old child, I am terrified about her being infected. “

ASHA workers also face multiple challenges of being a woman health worker working on low wages in high risk conditions and without any adequate training. Earlier ASHA workers used to visit houses and talk to the women while the men of the households were not at home. This made it easier for the ASHA workers to get crucial health-related information from the household. But during the lockdown, the ASHA workers have to face the disdain from the men of the household and even violent behaviour since they are seen as a threat of passing on the virus to the family.

Demands for Rights of Asha Workers

On 28 April, the World Health Organisation called upon all governments, employers, and worker organisations and the global community to take urgent measures to protect occupational health and safety of health workers and emergency responders respect their rights to decent working conditions, and develop national programmes for occupational health of health workers and to provide them with occupational health services.

It is imperative that ASHA workers who are essential to securing the lives of millions in India yet continue to be exposed to the hazards of the pandemic, particularly long working hours, fatigue, psychological distress, burnout, stigma and physical and psychological violence, are brought within the social and legal protection guaranteed to healthcare workers.

In addition, Amnesty International India demands the central and state governments to immediately take the following measures:

  • Provide proper Personal Protective Equipment (PPE) for all ASHA workers across the country with timely re-provisioning of masks and gloves.
  • Regularise the services of ASHA workers and bring them under the official definition of ‘worker’ under relevant labour laws.
  • Provide decent wages for COVID-related work and increase the core incentive for ASHA Workers in all states, in sync with the demands of the ASHA workers unions and statutory minimum wages for skilled workers.
  • Provide adequate and proper treatment and compensation for loss of work in the event of contracting COVID-19 as part of ASHA workers’ interface with the community.
  • Provide adequate health insurance coverage for treatment and care in case of illness irrespective of COVID-19.
  • Immediately fill vacancies of ASHA workers currently pending across states.
  • Launch a maternity scheme for ASHA workers which caters to their care during pregnancy and motherhood.
  • Provide other social security benefits such as inclusion in Employees’ State Insurance and Employee Provident Fund amongst others.
  • Provide adequate and regular training on disease prevention and infection control.

The Right to health is a fundamental right under the Indian Constitution. Under the International Covenant on Economic, Social and Cultural Rights (ICESCR), to which India is a state party, all workers have the right to just and favourable conditions of work. This includes the right to fair wages, equal pay for work of equal value, safe and healthy working conditions, reasonable limitations on working hours, protections for workers during and after pregnancy, and equality of treatment in employment.

The ASHA workers have revolutionised the access to maternal and child health care and primary health care in India. While we try to show our gratitude to them by ‘floral salute’ and other displays, mere gratitude is not enough. They require humane treatment with adequate institutional support for doing their work.

“We know, we are manyatha praptha samajik aarogya karmic (Accredited Social Health Activist). We come with the purpose of serving the society at heart,” said Indu*, an ASHA worker. “We have worked tirelessly and are ready to work more. But we cannot sustain ourselves without proper support.”

In the time of an unprecedented pandemic, these women have proven to be indispensable. Meeting their basic demands will only bolster our own readiness for such pandemics and ensure that communities become more resilient.

By Aswati Warrier, Human Rights Education Officer at Amnesty India.