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Delayed Payments Dampen Health Workers’ Motivation

Frontline health workers, especially ASHA workers, literally spell hope for millions in rural India, but the government does little to keep them incentivised.

With less than five practising doctors per 10,000 persons, India’s public health system is battling a severe crisis, especially in the rural areas where many doctors are often reluctant to practise. The government’s incentives and rules have not changed the situation much. But doctors are not the only lifeline of the healthcare system in rural areas, community health workers are equally important. Clad in pink uniforms, going door-to-door filling up registers and forms, vaccinating women and children and providing information and counselling, India’s army of 860,000 ASHA workers are the linchpin of the system.

Accredited Social Health Activists (ASHAs)  are recruited by the National Rural Health Mission (NRHM) and are trained to be the “first port of call” for all health-related issues in a village. As the title suggests, ASHA workers are not just providers of healthcare but activists who promote healthcare practices and make healthcare a matter of community participation.

As promoters of social health, they also address the social determinants of health, or what seem to be external factors determining access to and quality of healthcare. For instance, ASHA workers have been credited for playing a crucial role in bringing down India’s infant mortality rate from 50 deaths per 1000 live births to 34 deaths per 1000 live births between 2005 and 2016. In West Bengal, they have been instrumental in detaching the patriarchal stigma from male sterilisation.

When Swati was recruited as an ASHA worker in 2007, she was excited to be a part of a workforce that has been instrumental in bringing so much change, and was content with the voluntary status as well. Even as payments staggered, she continued to do her work with a sense of duty, but confessed that it was demotivating to work without proper payment.

Swati is one of Jharkhand’s 39,380 ASHA workers, known as Sahiyas in the state. In July 2017, Community Correspondent Nirmala Ekka reported that at least 75 ASHA workers in Ranchi’s Ratu block had not been receiving their dues since 2015 and some of them had arrears of 60,000 rupees and upwards.

On an ordinary day, Swati and her colleagues spend the day on their feet gathering crucial health-related information from households in the village, holding meetings, talking to women, counselling their families, taking patients to the nearest hospitals, ensuring follow-up treatment and more. Despite providing such vital services, ASHA workers are given the status of volunteers rather than employees of the NRHM.

As volunteers, they are paid an honorarium for each task they perform as opposed to a fixed salary, they have little job security and many a time, little respect from government authorities and even local residents. While doctors are incentivised with ‘hard area allowance’ and the likes for working in rural areas, frontline health workers are barely even paid on time, let alone being given incentives and perks.

Over the last one year or more, ASHAs, along with ANMs (auxiliary nurse-midwives) and other community health workers have taken to the streets and demanded formal employment and regularisation of salaries along with better working conditions.

Laxmi Kaurav, an ASHA worker and Video Volunteers Community Correspondent, has been leading one such strike in Bhind, Madhya Pradesh. Kaurav and her group have been on strike since March 8, International Women’s Day, demanding their rights as women and as workers. The local Member of Parliament promised action after they went on a hunger strike but the workers have also been threatened with suspension or termination of service.


In Bihar too, frontline health workers had been threatened with termination of service if they didn’t lift their strike demanding regularisation of service. Meanwhile, in Gujarat, the honorarium amount went up by 50 percent as the state polls approached in 2017.

The government’s treatment of such a crucial part of the health sector workforce is deplorable. The NRHM acknowledges that ASHAs cannot function without adequate institutional support-- from local self-governance bodies, training organisations and from local voluntary groups, but does not always provide this support, along with financial security, and fails to keep them motivated. The skills and services that frontline health workers provide are a goldmine for India’s public health system and failing health workers means failing the healthcare needs of millions.

Video by Community Correspondent Nirmala Ekka

Article by Alankrita Anand, a member of the VV Editorial Team

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