Behind ASHA protests in Kerala: Demand for increased honorariums, other benefits

Venugopal also drew attention to protests by ASHA workers outside the secretariat in Thiruvananthapuram, ongoing for more than a month now.

Health Minister J P Nadda informed Rajya Sabha that the Steering Group of the National Health Mission (NHM) had approved increased incentives for ASHAs, which would come into effect soon.

Protests, blame game

Accredited Social Health Activists, or ASHAs, are community health volunteers serving in rural areas under the NHM.

On February 10, the Kerala ASHA Workers’ Association (KAHWA) began a sit-in protest outside the state secretariat to press three demands: release of pending dues, increasing the honorarium – the amount paid to ASHA workers – from the current Rs 7,000 to Rs 21,000, and retirement benefits of Rs 5 lakh.

The protesters reiterated the long-standing demand for ASHA workers to be made regular employees.

Kerala’s CPM-led government has accused the Centre of not disbursing Rs 100 crore in health funds due to the state for 2023-24. However, Nadda said on Tuesday that all dues had been cleared, and alleged that Kerala had delayed the process by not furnishing a ‘utilisation certificate’ saying the funds had been used for their intended purpose.

The state has also alleged that vested interests have hijacked the protests, and that the protesters have “fallen into the trap of anarchist groups”.

Role of the ASHA

The National Rural Health Mission (NRHM), which was launched in 2005, mooted ASHAs as a new band of community health functionaries who would work in rural areas alongside the anganwadi workers (AWWs) of the Integrated Child Development Scheme (ICDS).

(NRHM and National Urban Health Mission were subsumed in the NHM, which was launched in 2013.)

“ASHA will be the first port of call for any health-related demands of deprived sections of the population, especially women and children, who find it difficult to access health services,” a policy document introducing the scheme said.

ASHAs are expected to disseminate awareness of good health practices and help marginalised communities utilise available public health services such as primary health centres and district hospitals.

They support maternal and child care, enforce immunisation drives, and help with family planning initiatives and disease-based prevention and mitigation programmes.

They also carry out periodic home visits, and keep a record of their progress in diaries.

An ASHA is typically a woman resident of the village she serves, between the ages of 25 and 45. Preference is given to married, widowed, and divorced women, and those who have studied up to Class 10.

They are chosen in a rigorous selection process that involves gram panchayats, anganwadi institutions, community groups, and self-help groups.

The scheme envisaged one ASHA per 1,000 population. According to the most recent ASHA update released by the Ministry of Health and Family Welfare in 2022-23, there were 9.2 lakh rural ASHAs and around 79,900 urban ASHAs around the country.

The largest numbers of rural ASHA workers were in Uttar Pradesh, Bihar, Chhattisgarh, and Madhya Pradesh, according to the update.

What the ASHAs earn

When the scheme was framed in 2005, ASHAs were imagined as honorary volunteers whose “work would be so tailored that it does not interfere with (their) normal livelihood”.

But this is no longer the case, given their crucial role as the first point of contact for marginalised households seeking healthcare. Many ASHAs are engaged in the profession full-time.

However, the NHM sees ASHAs as volunteers and not employees, which makes them ineligible for earnings beyond task- or activity-based incentives.

All ASHAs are entitled to a monthly incentive of Rs 3,000, which is split between the Centre and the state.

However, Raji K, an ASHA in Kerala, told The Indian Express that payment of the monthly incentive was incumbent on their completing specific tasks – and was often not paid in full.

This is because certain schemes, such as the Rashtriya Bal Swasthya Karyakram that focuses on early childcare, have limited applicability in districts with low childbirths, Ajitha, an ASHA from Kollam, said.

Kerala ASHAs are entitled to Rs 500 for the Rashtriya Bal Swasthya Karyakram.

ASHAs also receive an honorarium, which the state or Union Territory concerned pays from its own funds. In Kerala, the monthly honorarium is Rs 7,000. However, the receipt of this amount depends on the ASHA completing 10 tasks – running a clinic, maintaining the ward report, community outreach, etc., each valued at Rs 700 – Raji said.

ASHAs also earn task-based incentives under national health schemes, which vary from scheme to scheme and its applicability in a certain ward or area.

Kerala vs other states

While Kerala Health Minister Veena George claimed last week that the Rs 7,000 honorarium paid by the state was the highest in the country, a few other states pay a higher amount.

Sikkim has been paying Rs 10,000 to ASHAs since October 2022. And this month, Andhra Pradesh increased the honorarium to Rs 10,000, and also instituted a gratuity of Rs 1.5 lakh for ASHAs who have completed 30 years of service.

In January, Karnataka raised the monthly honorarium from Rs 5,000 to Rs 10,000, effective from April, after ASHAs in the state began an indefinite strike seeking a fixed monthly honorarium of Rs 15,000 and other benefits.